NCM 109 LECTURE – PRELIMS labor and birth and arrival of her labor,
and (3) helping a woman learn more about IDENTIFYING A HIGH-RISK PREGNANCY
NURSING CARE OF THE HIGHRISK
PREGNANT CLIENT: ASSESSING A WOMAN
AT RISK
• When a woman enters pregnancy with a
chronic condition such as cardiovascular or
kidney disease, both she and the fetus
could be at risk for complications
• Either the pregnancy that complicate the
disease or the disease can complicate the
pregnancy
• Affecting the baby or leaving the woman
less equipped to function in the future
• Nursing care for a woman with a
preexisting illness focuses on close
observation of maternal health and fetal
well-being
• Education of a woman and her family
about the special danger signs to watch
during pregnancy and actions to minimize
complications whenever possible
• A pregnant woman may develop a new
illness during pregnancy, when this occurs
the illness could adversely affect not only
the woman but also her unborn child
• Nursing for the well pregnant woman
focuses on preventing illness by promoting
special lifestyle
• When accidents and illness occurs, nursing
care focuses on the ff: (1) preventing such
disorders from affecting the health of the
fetus, (2) helping the women regain her
health as quickly as possible so she can
continue a healthy pregnancy and prepare
herself psychologically and physically for
her chronic illness so she can continue to
safeguard her health during her
childrearing years
FOCUS ON NATIONAL HEALTH GOALS
• Conditions that cause severe symptoms such
as change in fluid and electrolyte balance,
altered cardiovascular/respiratory
function, severe blood loss are specially
dangerous to a fetus. Thus, national health
goals r/t pregnancy has been established
→ Reduce the rate of fetal deaths to 4.1 per
1000 live births from a baseline of 6.8
per 1000
→ Reduce the rate of maternal deaths to 3.3
per 100,000 live births from a baseline of
7.1 per 100,000
→ Reduce the rate of maternal illness and
complications during pregnancy to 24 per
1000 births from a baseline of 31.2 per
100
• Nurses can help the nation reach these
goals by educating women about the
importance of entering pregnancy in the
best state of health possible
• Helping women with Diabetes Mellitus
understand the importance of pre-
pregnancy care. They enter pregnancy
without hyperglycemia, is an important step
towards reducing congenital anomalies in
newborns
• Supporting women with kidney, heart and
respiratory disease to continue to follow
their medical regimen
HIGH-RISK PREGNANCY
• Concurrent disorder, pregnancy-related
complications, or external factors
jeopardize health of woman, fetus, or both.
• Some women enter with chronic illness that
when superimposed on the pregnancy
makes it high risk
• In some instances, a combination of a
particular circumstances, such as poverty,
lack of support people, poor coping
mechanism, genetic inheritance or past
history of pregnancy complications can
cause a pregnancy to be categorized as
high risk
• Pregnancy of a woman who is diabetic is
automatically termed as one with greater
than normal risk because it forces fetus to
grow in an environment in which
hyperglycemia or increased serum glucose
levels becomes the root
→ At birth, her child in double jeopardy,
altered glucose metabolism, and high risk
for poor maternal/parent–child
attachment
FACTORS THAT CATEGORIZE A
PREGNANCY AS HIGH RISK:
PSYCHOLOGICAL
• During pre-pregnancy
→ History of drug dependence.
→ History of intimate partner abuse.
→ History of mental illness.
→ History of poor coping mechanism.
1
 → Cognitively challenged & survivor of
childhood sexual abuse
• During pregnancy
→ Loss of support persons
→ illness of a family member
→ decrease in self-esteem
→ drug abuse
→ poor acceptance of pregnancy.
• During labor and birth
→ Severely frightened by labor and birth
experience
→ Inability to participate because of
anesthesia.
→ Separation of infants at birth
→ Lack of preparation for labor
→ Birth of an infant who is disappointing in
some way illness in a newborn
SOCIAL
• Pre pregnancy
→ occupation involving handling of toxic
substances
→ Environmental contaminants at home
→ Isolation
→ Lower economic level
→ Poor access to transportation for care,
High altitude, highly mobile livestock,
→ Poor housing, and lack of support people
• During the pregnancy
→ refusal of or neglected prenatal care,
→ exposure to environmental teratogens,
disruptive family incidents,
→ decreased economic support,
→ conception less than one year after last
pregnancy
• During labor and birth
→ lack of support person,
→ Inadequate home for infant care and
plan, cesarean birth,
→ lack of access to continued health care,
→ and lack of access to emergency
personnel or equipment
PHYSICAL
• Pre pregnancy
→ visual or hearing challenges,
→ pelvic inadequacy or misshape,
→ uterine incompetence position or structure
→ Secondary major illnesses poor
gynecologic or obstetric history, history of
previous poor pregnancy outcome, history
of child with congenital anomalies
→ Obesity, underweight, pelvic inflammatory
disease history of inherited disorder
→ Small stature
→ potential of blood incompatibility younger
than age 18 or older than 35 years old
→ Cigarette smoker and substance abuse
• During the pregnancy
→ subject to trauma fluid or electrolyte
imbalance
→ Intake of teratogens such as drug, multiple
gestation
→ bleeding disruption, poor placental
formation or position
→ gestational diabetes
→ Nutritional deficiency of iron, folic acid or
protein
→ Poor weight gain
→ Pregnancy induced hypertension, infection,
→ amniotic fluid abnormality
→ post maturity
• Labor and birth
→ hemorrhage, faction, fluid, and
electrolyte imbalance, dystocia,
precipitous birth, lacerations of cervix or
vagina, cephalopelvic disproportion,
internal fetal monitoring, and retained
placenta
 Categorizing risks as minimal, moderate or
extensive differs with each woman because
of their individual coping mechanism and
level of support
 A woman living in extreme poverty who
does not have access to community support
would be at higher risk for poor nutritional
intake during pregnancy
 Whereas a woman who has a similar
income who could depend on a nutritional
assistance program & counseling from a
community health nurse might only be at
minimal risk
 “High-Risk” – rarely refers to just one
causative factor helps in the planning of
holistic and ultimately effective nursing
care
VULNERABLE (HIGH RISK) GROUPS OF
WOMEN
PREGNANT ADOLESCNETS
• Risk: PIH, Anemia, & Preterm Labor
• Adolescent pregnancy is not new
phenomenon
2
• Historically, it was common for women to
marry at age 12 or 13 and first baby at
15
• In today’s society, marriage & childbearing
are life situations that are thought of as
belonging to later years.
• Teenage pregnancy still continue. Reasons
for the high number of them include
→ Earlier age menarche in girls
→ Increased rate of sexual activity
(teenagers)
→ Lack of knowledge or failure to use
contraceptives or abstinence and the
desire by young girls to have a child
→ Some adolescents become pregnant as
result of rape or incest
• Failure of adolescence to obtain adequate
knowledge of contraceptive measures or
abstinence is an issue can be addressed by
healthcare providers as protective
measures are easy to use, adolescents
should not have difficulty following
instructions
• Adolescents are also capable of using
emergency contraception correctly and
safely
• Access to emergency contraception is not
associated with increases rates of
protected sex or higher rates of pregnancy
or Sexually Transmitted Infections
• Providing this type of information does not
always resolve the problem, because
adolescence may lack money to purchase
protection such as birth control pills or
diaphragm
• The egocentric phenomenon of adolescence
makes a sexually active teenager believe
she will not become pregnant
• Some adolescent girls actually plan
pregnancy. They believe being pregnant
will free them from intolerable school or
home situation and give them someone to
love and someone to love them
• This puts tremendous responsibility on
newborn to furnish love and change a girl's
life. And child abuse occur when newborn
can’t meet such expectation
• At one time, pregnant unmarried girls were
sent to a secret home, where they would
stay throughout pregnancy, give birth,
place child for adoption and return home
as if nothing had happened to them
• Today, pregnant teenagers remain at
home, attend prenatal clinics or come to
physicians offices just as older women
• They give birth in birthing rooms at
hospitals and as many as 90% keep their
babies
• Few give birth in alternative birthcenters
because of the risk of Cephalopelvic
disproportion makes adolescent
pregnancies high risk
• Home birth not recommended for same
reason.
• Offering increased guidance during
pregnancy and for child care during
following years can be important nursing
role.
• Adolescents is a vulnerable time for
pregnancy because the developmental
tasks of pregnancy are superimposed on
those of adolescents
• The developmental tasks of the average
adolescents are fourfold to establish a
sense of self worth or value system, to
emancipate from parents to adjust to new
body image and to choose a vocation.
• Girl in process of separating from her
parents may be devastated by reality of
someone else being dependent on her. She
need her parents financial help more than
ever to obtain prenatal care and buy
clothing for her new baby. If she must
depend on her parents' health insurance,
may feel virtually trapped into
dependence.
• Helping adolescents to make their own
healthcare decisions at health care visits
helps to foster a sense of independence in
the middle of this force dependency.
• Parents may have difficulty allowing a
doctor to make her own health care
decisions.
• Need to remind that pregnant adolescent is
regarded as an emancipated minor or a
mature minor, a person capable of making
health, decisions, and may sign permission
for her own care.
→ Soon she will be caring for an infant, so
needs this practice in independence and
responsibility.
→ Pregnancy may interfere with
development of a healthy sexual
relationship and cause difficulty in
establishing future intimate relationships if
a girl realizes that her current relationship
3
 has lead to a situation detrimental for her.
Useful to help her build pregnancy as a
growth producing experience.
→ Establishing value system or sense of
identity can be difficult if health care
personnel treat a pregnant adolescent as
though she is responsible, encouraging her
to continue school is crucial to her self
esteem and to her future, and future of
her unborn child.
→ Many schools have special programs for
pregnant adolescence that include aspects
of prenatal care
→ Adolescents are considered high risk
clients because they have high incidence
of pregnancy induced hypertension, iron
deficiency anemia and premature labor.
They also have a higher incidence of low
birth weight infants, Cephalopelvic
disproportion, and high rate of intimate
partner abuse
• Early & consistent prenatal care is essential
to their health and to the health of their
baby.
ASSESSMENT INDICATORS
PRENATAL ASSESSMENT
• Unfortunately, many adolescents do not
seek Prenatal care until late of their
pregnancies as this is a way of protecting
the pregnancy. If she doesn't tell anyone,
no one can suggest she terminate the
pregnancy
• After 6th month, abortion is no longer a
possibility so she can feel free to come for
care without being subjected to this
pressure
• Other factors to lack of prenatal care:
denial, lack of knowledge of importance of
prenatal care, dependence for
transportation, feeling awkward in
prenatal setting, fear of first pelvic
examination and difficulty relating to
authority figures
• Primary nursing or case management
approach that minimizes number of
healthcare providers a teenager is
exposed to maybe most effective method
for providing care during prenatal period
• Some adolescents do well in group
prenatal care because it allows them to
interact with a peer
• If community does not have facility
designed especially for adolescents, all
settings should accommodate adolescence
needs, thus eliminating this reason for poor
prenatal care
HEALTH HISTORY
• We take a detailed health history at first
prenatal visit of adolescent to establish
individual risk. This is done without the girl's
parents present. The girl needs to practice
in being responsible for her own health,
and having to account for health practices
• Prevent her from fabricating an answer to
please a parent.
• Some adolescents come to facility with
concerns such as weight gain or feeling
tired all the time rather than saying they
are pregnant. Healthcare providers will
think of pregnancy as possible reason for
their symptoms. This is part denial and part
pregnancy protection. Always be alert to
possibility when adolescent describes
symptoms that are vague and hard to
define.
• If the importance of what she is saying
when she mentions feeling tired or
nauseated is missed, she may ask if
someone will feel her stomach. If told this,
not necessary for any of symptoms.
• She may describe bigger symptoms such as
terrible stomach pain, think of possible
pregnancy when you hear such a growing
history
• Many adolescents want to keep their world
totally separated from adult world and to
keep it separate, they do not voluntarily
share information with adults
• When interviewing adolescents be certain
to press for the responses needed to assess
safety
• Ask for details
• If adolescent delayed seeking health care
asks for reason at her first prenatal visit,
acknowledge that protecting the
pregnancy is desirable motive, but
continuing with prenatal care is more
beneficial
• If a parent does accompany, ask parent
separately “what”, if any, concerns he or
she wishes to discuss
• A young adolescent is still a daughter, and
parent may be as concerned about their
health during this pregnancy as the parent
was at health visits while the girl is being
seen for cold/sports injury
4
• A baby's father may accompany a
teenage girl into clinic to have pregnancy
diagnosis established because he is not
married to her, he does not have legal
right to participate in her decision
concerning pregnancy, abortion or
adoption, but he may not be devoid of
feelings for girl or baby
• If he is an adolescent, he may feel sorrow
that because of his age, he cannot provide
adequately for the girl and baby
• If complications occur, he may feel genuine
grit, allowing him to offer support in current
pregnancy helps him to learn more about
himself and better define his role
• Be sure he receives compassionate
education on preventing further
pregnancies until he is more mature
• Often girls have not talked much so need
extra teaching to help them become aware
of common pregnancy symptoms such as
urinary frequency, fatigue, and breast
tenderness
• Asking what symptoms an adolescent is
having and reassuring her part of normal
pregnancy, can help prevent from
attempting to treat them with potentially
teratogenic over-the-counter medication
• As pregnancy progresses, listen for signs of
nest building behavior during a pregnancy
history.
• An adolescent girl may not have the
financial resources to buy clothing or bed.
• She may reveal less building feelings by
asking an increasing number of questions
about newborns.
• Offer suggestions such as making one
article of clothing for baby, or saving her
own money for one article
• Activities that promote active involvement
in pregnancy and provide a measure of
nesting behavior.
• Some adolescents have difficulty telling
their parents about the pregnancy
• Role-playing or simulation may be
effective technique to help them prepare to
do this. Some girls report on second visit
that their parents were not nearly as angry
as they had anticipated. Instead, their
parents reacted as they had been waiting
to hear this news. Having accepted is as
inevitable moments before.
FAMILY PROFILE
• Adolescents may leave home if family
disapproves of their pregnancy
• Joining ranks of homeless or adolescent
runaways
• Others, do not leave home but separate
themselves emotionally from family. Trying
to manage by themselves leaves with
tremendous financial strain and
devastating sense of loneliness
• Be sure to ask a girl at prenatal visits
where she is living, source of income, and
whom she would call if she suddenly
become ill
• Asking about home life may reveal
dysfunctional family or an incest
relationship as the cause of the pregnancy
→ If girl is under legal age, incest is
considered child abuse. Know local and
state law and make the necessary report
→ Because of family relationship problems,
girl may need help in making
arrangement for next few months of her
pregnancy and for childcare afterwards
• Be certain to ask if girl is planning to
continue with school
→ Pregnancy is an egocentric time when
outside interests do not always seem
important
→ Help her to see that months of pregnancy
will go by faster if she is busy
→ Remaining in school in a way of helping
her stay busy.
→ Also important in preparing for future
because a high school education will be
necessary to obtain marketable skills, to
support herself and her baby.
→ Once she has given birth, returning to
school may be difficult because she may
have child care problems and feel more
mature
→ Any school that obtains federal money
cannot discriminate against students
because they are physically challenged.
→ Many states interpret pregnancy as
physically challenging, girl cannot be
forced to leave school because of
pregnancy.
→ You may need to advocate for a girl with
a school committee for proper school
placement.
PHYSICAL EXAMINATION
• Physical examination procedures with
pertinent adolescent findings should be
explained to the pregnant adolescent.
5
PREGNANCY EDUCATION
• Adolescents need great deal of health
teachings during pregnancy because they
do not know many common measures of
care that an older woman has learned
from experience
• They also often unwilling to follow
healthcare advice that makes them difficult
in any way from their peers.
• Adolescents often do not have well
established health practices, so they are
adaptable
• Adolescents also need instructions on
possible discomforts & changes associated
with pregnancy and measures to relieve
them
NUTRITION
• Good nutrition can be a major problem
during an adolescent pregnancy because
many enter pregnancy with poor nutritional
stores from years of eating less than
optimal diet
• Lack of good nutrition can result in preterm
birth and low birth newborns
• The younger the girl, the more likely to
have a low birth weight infant
• To prevent this complications, a girl should
eat sufficient diet to allow for growth of a
fetus and provide for needs of her own
growing body
• Otherwise, protein, iron, folic acid, vit A
and C deficiencies may become acute
• She may need to gain more weight than
does the mature woman to supply
adequate nutrients.
ACTIVITY & REST
• Adolescents vary greatly in level of
activity.
• Assess the girl's participation in sports &
determine which ones may have to be
discontinued during pregnancy
• Many girls practice sports not for
enjoyment of sport, but for feeling of team
or companionship. Suggest alternative
activities to not suffer from loss of
companionship
• Adolescents may not plan enough rest time
during pregnancy, especially if they are
acting up as if nothing is happening to
them.
• It may help to explore a typical day and
suggest ways to rest without compromising
social relationships
CHILDBIRTH PREPARATIONS
• Adolescents have a strong need for peer
companionship.
• When they become pregnant, often are cut
off from fellow adolescents
• Therefore, they join class of adolescence in
preparation for childbirth.
• They are excellent students because being
a student is age appropriate for them.
• They have enough childish magical belief
operating that they are not skeptical about
whether prepared childbirth will work
• In fact, believing that prepared childbirth
will work is an important component and
successful prepared childbirth experience.
So this becomes a self fulfilling prophecy.
BIRTH DECISIONS
• Pelvic measurements should be taken early
and carefully in adolescent girls.
• Cephalopelvic Disproportion (CPD) is a
real possibility because of girl's incomplete
pelvic growth
• Most girls are told their baby will have to
be born by cesarean birth, respond well to
the news, and many are relieved because
surgery seems controlled and simple
compared with the agonies of labor they
imagine
• When CS birth must be scheduled because
of CPD or poor fetal growth, the
information should be shared with girl and
her parents as soon as possible
• Adolescents wants to know the truth, they
tend to regard withholding of information
not as protection, but as indication they are
being treated as children
PLANS FOR THE BABY
• Adolescents may need additional time at
prenatal visits to talk to a good listener
about how they feel about being pregnant
and becoming a mother
• Be certain they know all options available
to them, keeping the baby, placing the
baby in temporary foster home or
adoptions.
• Adolescents, like all women, should be
encouraged to breastfeed
• Breast tissue matures with pregnancy. Even
the young adolescent is physically capable
of breastfeeding
6
COMPLICATIONS
• Adolescent pregnancy carries an increased
incidence of pregnancy induced
Hypertension, iron deficiency anemia,
preterm labor, and CPD
• Proportionately, with consensus prenatal
care, complications minimized.
PREGNANT WOMAN OVER AGE 40
• Risk of hypertension, varicosities,
hemorrhoids
• Has a major role change to undertake
compared to a young pregnant adolescent
→ Incidence of women delaying their first
pregnancy until late 30s or early 40s is
increasing
→ 12% of births in US are women over
age 35
→ 2 to 4% are women over age
• In past, assumed woman of this age was
past the optimal age for childbearing and
at risk for many complications
• Today, with the exception of a greater
incidence of chromosomal abnormality,
there is little evidence of serious
complications in women older than age 40
as long as prenatal care has begun early
in the pregnancy
• A woman over age 40 is more likely than a
younger woman to have previously
diagnosed condition such as hypertension,
varicosities, or hemorrhoids
• A woman usually has a higher role change
to undertake during pregnancy because
she often is well established in a career or
has an accustomed routine at home or in
her community, she needs to think through
how this pregnancy and childrearing are
going to fit into and change her life
• Although may feel rich in the number of
support people she perceives around her,
she may discover she has few pregnancy
support people because she does not have
many friends her age who are also having
babies.
• Some may be close to becoming
grandparents.
• The only thing these friends remember of
pregnancy and labor or their particular
highs and lows and care they received
may not reflect current practice
→ This may leave woman without access to
talk of other pregnant women or someone
to turn to questions such as whether
backache she is experiencing or frequent
need to urinate is normal
→ On the other hand, because many women
delay childbearing today, she may be the
one of a sizable group of women in her
community experiencing pregnancy at this
stage of life.
• The developmental challenge of woman
over age 40 expand awareness or
develop generativity, that is the sense of
moving away from themselves and
becoming involved in the world or
community
• Some people assume that once they reach
adulthood, the way they are is the way
they will always be
• They are amazed to find that their bodies
change and so their interest
• They find themselves joining committees
and clubs or organizing fundraising or
community events
• A woman in this age group who is pregnant
may begin to feel ambivalent during
pregnancy because she may want to
continue with community activities, yet, also
wants to concentrate on baby inside her
• You may need to help her balance her life
so she can manage crossing 2 live phases
this way
• What is perceived as the best time in life
to have children is culturally influenced
→ In developing countries many believe
having children while young allows
parents to grow with children
→ In other cultures such as the US, many
believe delaying childbirth until family is
financially secure is best
→ Delaying child birth too long, however, is
not approved
→ Because of these various beliefs what you
believe may not be the belief of a family
for whom you provide care
→ What may be a catastrophe to you may
seem like a blessing to someone else
→ Assess couple by history and observations
to determine if childbearing appears to
be time correctly for them. If not, they
may need extra time to accept pregnancy
and adapt to becoming parents
• Women who have child after age 40, fall
into 1 of 2 groups: those having their final
child and those who have delayed
childbearing because of education or
career and are having their first child
7
• Many adults over the age 40, care for
aging parents
• This additional responsibility may make it
difficult for a woman to complete the
psychological work of pregnancy. It also
may create extra strain on her finances
and time
• Worries include having enough energy,
arranging for child care and financial
strength
ASSESSMENT INDICATORS
PRENATAL ASSESSMENT
• Women over age 40, like all women
should gain prenatal care early in
pregnancy
• Fortunately, most women of this age group
are well informed about the advisability of
early prenatal care and have adequate
health insurance so they seek an early
appointment
→ A few mistakenly believe their lack of
menstruation is a result of early
menopause
→ So they do not seek an early health care
consultation
HEALTH HISTORY
• Ask women about present symptoms of
pregnancy: how they feel about pregnancy
and how it fits into their lifestyle.
→ If woman did not realize she was
pregnant, may have self-medicated
medication or herbal remedies to relieve
reported symptoms.
→ Because a woman is functioning well in a
business world does not mean she has a
healthy pregnancy lifestyle
→ Do not accept answers like “I drink
socially” or” I take usual drugs” without
exploring what those phrases mean
specifically
PHYSICAL EXAMINATION
• A woman over age 40 needs thorough
physical exam at the first prenatal visit to
establish general health and to identify
any problems particularly circulatory
disturbances she may have
→ Inspect lower extremities thoroughly for
varicosities because these are more
common in women over age 40
→ Obtain urine specimen, test for specific
gravity, glucose, and protein to evaluate
overall renal function and possibility of
gestational or type 2 diabetes because
older women are more prone to develop
these conditions
→ Assess woman's breasts for any
abnormalities as women over age 40
are in higher risk group for breast cancer
than younger women, ask if she has had
yearly mammograms.
→ Asses for FH sounds and fetal movement
at prenatal visits because gestational
trophoblastic disease is more common
more common in age 40
CHROMOSOMAL ASSESSMENT
• Women over 35 are offered a triple
screen or alpha fetoprotein, Human
Chorionic Gonadotropin (hCG), and
unconjugated estriol levels drawn on blood
serum at 15th week of pregnancy to detect
whether an open spinal cord or
chromosomal defect could be present in
fetus, because their risk for Down syndrome
is so much higher than it is in the younger
women
• An incidence in about 1 in 1000 compared
to 1 in 1500 in younger women
• If test is positive, amniocentesis will be
scheduled at 16th week of pregnancy
• Be certain woman is prepared for these
studies and receives support
• Alert her that false positive results can
occur with alpha fetoprotein testing which is
why amniocentesis is important.
• Many women of this age group do not
begin nest building until the test confirms
that child will be healthy.
PREGNANCY EDUCATION
• Childbirth education classes oriented
toward the older woman provide important
information on pregnancy & bring these
women and support people together
• A woman over age 40, needs access to
health care personnel who can supply
factual info during pregnancy
• She also needs additional support while
she works through this role change in her
life
NUTRITION
• Assess number of meals woman eats
outside her home each week, including
pack lunch or eats in restaurants
• She may needs tips on how to adjust
pregnancy nutrition so she can obtain the
same nutrition whether she prepares meal
8
 at home or eats them at office or
community function
• Urge her to substitute caffeine free soft
drink in place of an alcohol beverage.
• In some offices, large amount of coffee is
consumed. Urge to substitute milk or juice or
decaffeinated coffee.
• Many women this age normally drink little
milk rather than getting used to milk again,
a woman may appreciate Suggestion other
ways to ingest calcium, such as puddings or
yogurt
PRENATAL CLASSES
• A pregnant woman over age 40 may be
unique in her circle of friends, she may feel
shut out of usual group because of the
pregnancy
• This makes her ready to join childbirth
preparation or prenatal exercise class
where she is one of the group
• Be certain woman plans to set aside
specific time every day to do breathing
exercises in preparation for labor
• A busy woman may never find time to get
to them and will be unprepared in labor.
COMPLICATIONS OF PREGNANCY
• Most likely to occur in women over age 40
are hypertension of pregnancy, pre-
term/post-term birth and CS Birth
• These are related to the fact that the
woman circulatory system may not be
competent as when she was younger or
body tissues may not be as elastic as they
were once
WOMAN WHO IS PHYSICALLY OR
COGNITIVELY CHALLENGED
• Assess physical strengths as well as
limitations and psychosocial strengths as
well as challenges
• Plan for transportation, pregnancy
counseling, support person, health, work,
recreation, self-esteem
• In past, women with conditions such as
vision, hearing, cognitive, neurologic or
automatic challenges were sheltered by
families to such an extent that women with
evenly moderately, physically challenging
conditions could not meet potential sexual
or marriage partners and did not become
pregnant
• Most people believe these individuals
should not become pregnant.
• Today, women with varying degrees of
disability attend public schools, work in
offices, joint community organizations
establish sexual relationships, marry, and
plan pregnancies just like everyone else
• Urge women with physical or cognitive
disability or illness to come for pre
conceptual care so medicines taken can
be evaluated and careful planning for
safe pregnancy care can be started early
• Because these women face special
problems related to their conditions,
Nursing care during pregnancy must be
designed with the special concerns in mind
• So the woman and her family's problems
and needs can be addressed and met
A WOMAN WHO IS SUBSTANCE DEPENDENT
• Cocaine, Amphetamine, Marijuana,
Narcotic agonists - treatment of pain - eg
morphine or meperidine (Demerol) and
cough suppression(codeine)
• Analgesic and euphoric effects
• Substance dependence is growing health
problem in women of childbearing age,
incidence during pregnancy is increasing
• As many as 10 to 20% of pregnant use
illegal drug during pregnancy
• The use of cocaine, amphetamine and
multiple drug has increased dramatically in
recent years
• Adolescents have an increased rate of
inhalant abuse and binge drinking.
• Substance abuse is defined as the inability
to meet major role obligations, an increase
in legal problems or risk taking behavior or
exposure to hazardous situations because
of an addicting substance.
• A person is substance dependent when he
has withdrawal symptoms following
discontinuation of substance combined with
abandonment of important activities,
spending increased time and activities
related to substance use, using substances
for a longer time than planned or
continued use despite worsening problems
because of substance abuse
• Typically, substance dependent women are
thought to be in younger age group as the
overall incidence of drug use is highest in
this group.
9
• However, any woman could be substance • Common substance abuse during
dependent so all pregnant women need to pregnancy
be assessed for the possibility of this → Recreational drugs: cocaine,
• A mark of with substance abuse problem amphetamines, marijuana, Phencyclidine
may come late in pregnancy for prenatal inhalants, opiates, and alcohol
care because she is afraid her drug use
will be discovered and she will be
reported to authorities
• If she is using drug that sustains her for only
a few hours, she cannot wait long at a
healthcare facility to be seen for an
appointment.
• She may have difficulty following prenatal
instructions for proper nutrition because
although she may desire to eat well, she
may have sufficient money to buy both
drugs and nutritious food
• And choosing drugs over food makes her
nutrition inadequate
• She may not have money for supplemental
vitamins or iron preparations for the same
reason
• Illicit drugs tend to be of small molecular
weight, so they readily cross placenta as
result, a fetus of addicted mothers having a
drug concentration of 50% that of the
mother, because of this, this could lead to
fatal effects, drug abuse can account for
fetal abnormalities or preterm birth.
• If woman uses injected drugs, the risk for
hepatitis B or HIV infection increases
• A woman may earn money to buy drugs
through prostitution which increases the risk
for STI and poses an additional threat to
fetus

10
 NURSING CARE OF A FAMILY
EXPERIENCING A PREGNANCY
COMPLICATION FROM A PREEXISTING OR
NEWLY ACQUIRED ILLNESS
• Although pregnancy can be a stressful time
• Generally, women experience overall
good health during pregnancy perhaps in
part because of their extra care and
concern in keeping healthy for two
• This extra motivation also encourages a
woman with a high risk pregnancy to
carefully follow a therapeutic regimen that
established for her to keep herself and her
fetus safe
• This focuses on women who enter
pregnancy with a chronic condition such as
cardiovascular or kidney disease and those
who experience an intentional injury or
develop a chronic illness during pregnancy
DEFINITION OF A HIGH-RISK PREGNANCY
• A high-risk pregnancy is one in which a
concurrent disorder, pregnancy-related
complication, or external factor
jeopardizes the health of the woman, the
fetus, or both
NURSING PROCESS RELATED TO CARE OF A
WOMAN WITH A HIGH-RISK PREGNANCY
ASSESSMENT
• An accurate prenatal assessment of a
woman with a pre-existing or newly
acquired illness requires a thorough
understanding of the signs and symptoms
of the illness
→ Objective data - establishing baseline
vital signs
→ Subjective data - the extent of edema or
level of exhaustion a woman is
experiencing
• Such assessment is best made by
healthcare personnel who care for a
woman consistently throughout the
pregnancy so that a status changes can be
recognized
• It's also important to teach a woman how to
assess her own health in relation to
objective parameters
NURSING DIAGNOSES
• Nursing diagnosis developed for a woman
with a high-risk pregnancy address specific
disease-related conditions and therapeutic
restrictions her condition might require
• Example:
→ Ineffective tissue perfusion related to
poor heart function secondary to mitral
valve prolapse during pregnancy
→ Pain related to pyelonephritis secondary
to uterine pressure on ureters
OUTCOME IDENTIFICATION AND PLANNING
• Expected outcomes are realistic in light of
a woman's pregnancy and the restrictions
placed by her health
• Remember that one family member with
illness affects all family members so
therefore outcomes should relate to the
entire family's health
→ When making plans with pre-existing
medical condition, base them on the
pattern of her life before the pregnancy.
→ Example: to ensure receives enough rest
during pregnancy, planning for
afternoon rest period each day.
→ However, for woman with cardiac
disease who took two rest periods a day
before pregnancy, it would be
ineffective because she needs four rest
periods. A primary goal for a woman
with a severe chronic condition might be
to maintain her health during pregnancy
so she can remain at home as long as
possible thereby minimizing
hospitalization and family disruptions
PLANNING
• Planning for a new illness may be difficult
for a woman because of the shock of the
diagnosis
• You have to give a woman the available
alternative
→ Ex. “There are 2 possible therapies. Let
me review with you the advantages and
the disadvantages of each one.”
• Allowing a woman to choose among
alternatives in this way helps her to
participate in her own care and also
maintain self-esteem as well as helps her
move a step forward parenthood and
assuming care for her family
IMPLEMENTATION
• Nursing interventions for a pregnant
woman with a chronic illness may focus on
teaching her new or additional measures to
maintain health during the pregnancy
• Imaginative solutions to problems may
need to be created because otherwise a
11
 woman may be unable to adjust to the
extent of changes she must make
OUTCOME EVALUATION
• If an evaluation of outcomes and
healthcare visits reveals that an expected
outcome is not being met, a new assessment
analysis and planning need to be done.
• We have to do evaluation of our plan of
care or nursing care to our patient so that
we can see on what we need to improve,
do some revisions or probably do it from
the beginning again
• make evaluation ongoing to ensure that
you know throughout the pregnancy
whether interventions are successful
→ EXAMPLE: patient states that she rest for
two hours morning and afternoon
dependent edema remains at or at least
less at next prenatal visit
ESTABLISHING A BASELINE WHEN CARING
FOR A WOMAN WITH A HIGH-RISK
PREGNANCY
• 2020 National Health Goals Related to
Complications of Pregnancy
→ Reduce rate of fetal deaths to 5.6 per
1,000 live births from a baseline of 6.2
per 1,000 live births.
→ Reduce rate of maternal deaths to 11.4
per 100,000 live births from a baseline
of 12.7 per 100,000 live births.
→ Reduce rate of maternal illness and
complications during pregnancy to 28
per 100 births from 31.1 per 100 births.
HIGH-RISK PREGNANCY:
CARDIOVASCULAR SYSTEM
• Cardiovascular disease complicates only
1% of pregnancies but accounts for 5% of
maternal deaths.
• The number of women of childbearing age
who have heart disease is diminishing as
more and more congenital heart anomalies
are corrected in early infancy
• Rheumatic fever is being more actively
prevented and treated so that cardiac
damage from this disorder is also reduced
• A woman with cardiovascular disease
needs an interprofessional team approach
to care during pregnancy
• Ideally she should visit her pregnancy care
provider for preconception care so her
state of health and baseline data when she
is not pregnant can be established
• She could begin prenatal care as soon as
she suspects she is pregnant that is one
week after the first missed menstrual
period or as soon as she has a positive
home pregnancy test so her general
condition and circulatory system can be
monitored from the beginning of
pregnancy
• Blood volume and cardiac output increase
up to 50% during pregnancy (peaks at 28-
32 weeks), places stress on a compromised
heart
→ Half of this increase occurs by 8 weeks
→ it is maximized by mid pregnancy
→ Because of increased blood flow past
valves, functional (innocent) or transient
murmurs can be heard in many women
without heart disease during pregnancy
→ heart palpitations on sudden exertions
are also usual
CLASSIFICATION OF HEART DISEASE
I Uncompromised. Ordinary physical activity
causes no discomfort. No symptoms of cardiac
insufficiency and no anginal pain.
II Slightly compromised. Ordinary physical
activity causes excessive fatigue, palpitation,
and dyspnea or anginal pain.
III Markedly compromised. During less than
ordinary activity, woman experiences
excessive fatigue, palpitations, dyspnea, or
anginal pain.
IV Severely compromised. Woman is unable to
carry out any physical activity without
experiencing discomfort. Even at rest,
symptoms of cardiac insufficiency or anginal
pain are present
COMMON CARDIOVASCULAR CLINICAL
FINDINGS
LEFT-SIDED HEART FAILURE
• Orthopnea
• Paroxysmal nocturnal dyspnea
→ occurs in conditions such as the mitral
stenosis mitral insufficiency and aortic
coordination
→ In these instances, the left ventricle cannot
move the large volume of blood forward
that it has received by the left atrium from
the pulmonary circulation
→ this causes back pressure
12
→ The left side of the heart becomes
distended systemic blood pressure
decrease in the face of lower cardiac
output and pulmonary hypertension occurs
→ When pressure in the pulmonary veins
reaches a point of about 25 millimeter
per mercury, fluid begins to pass the
pulmonary capillary membranes into the
interstitial spaces surrounding the lung
alveoli and then into the alveoli
themselves so pulmonary edema produces
profound shortness of breath as it
interferes with oxygen carbon dioxide
exchange so if pulmonary capillaries
rupture under the pressure small amounts
of blood leak into the alveoli and the
woman develops a productive cough with
blood speckled sputum
→ Because of the limited oxygen exchange
a woman with left-sided heart failure is at
an extremely high risk for spontaneous
miscarriage, pre-term labor, or even
maternal death
→ As pulmonary edema becomes severe, a
woman cannot sleep in any position
except with her chest and head elevated
that is orthopnea, as elevating her chest
these waist allows fluid to settle to the
bottom of her lungs and free space for
gas exchange
→ She may also notice paroxysmal
nocturnal dyspnea, suddenly waking at
night with shortness of breath. This occurs
because heart action is more effective
when she is at rest with a more effective
heart action, interstitial fluid returns to the
circulation,
→ This overburdens her circulation causing
increased left side failure and increase
pulmonary edema n
RIGHT-SIDED HEART FAILURE
• Distended liver and spleen
• Ascites
• Peripheral Edema
→ Right-sided heart failure occurs when the
right ventricle is overwhelmed by the
amount of blood received by the right
atrium from the vena cava.
→ It can be caused by an unrepaired
congenital heart defect such as pulmonary
valve stenosis, but the anomaly most apt
to cause right-sided heart failure in
women of reproductive age is
Eisenmenger syndrome, a right-to-left
atrial or ventricular septal defect with an
accompanying pulmonary valve stenosis
→ With this, congestion of the systemic
venous circulation and decreased cardiac
output to the lungs occurs. Blood pressure
decreases in the aorta because less blood
is able to reach it; in contrast, pressure is
high in the vena cava from back pressure
of blood.
→ Both jugular venous distention and
increased portal circulation are evident.
→ The liver and spleen both become
distended. Extreme liver enlargement can
cause dyspnea and pain in a pregnant
woman because the enlarged liver, as it is
pressed upward by the enlarged uterus,
puts extreme pressure on the diaphragm.
→ Distention of abdominal and lower
extremity vessels can lead to exudate of
fluid from the vessels into the peritoneal
cavity (i.e., ascites) or peripheral edema
→ Women who have an uncorrected
anomaly of this type may be advised not
to become pregnant. If they do plan a
pregnancy, because they need oxygen
administration and frequent arterial blood
gas assessments to ensure fetal growth,
they can expect to be hospitalized for at
least some days during the last part of
pregnancy. During labor, they may need
a pulmonary artery catheter inserted to
monitor pulmonary pressure. Women with
this condition also need extremely close
monitoring after epidural anesthesia to
minimize the risk of hypotension.
CARDIOVASCULAR ISSUES
• The most common cause of difficulty during
pregnancy are valve damage concerns
caused by rheumatic fever or kawasaki
disease and congenital anomalies such as
atrial septal defect or uncorrected
coarctation of the aorta
• Aortic dilatation may occur from Marfan
syndrome
• As the number of women delaying their
first pregnancy until later in life increases
there is a corresponding increase in the
incidence of coronary artery disease and
varicosities during pregnancy
• In contrast, heart disease that occurs
specifically with pregnancy we have the
13
 peripartum heart disease still only rarely
occurs as it is apparently unrelated to age
→ with improved management of women
with cardiac disorders women who might
never have risked pregnancy in the past
are able to complete pregnancies
successfully today
CARDIOVASCULAR SYSTEM ASSESSMENT
• Nurses play a major role in
the care of pregnant
women with cardiovascular
disease because continuous
assessment of women’s
health status, health
education, and health
promotion activities are so
essential.
• Assessment begins with a thorough health
history to document prepregnancy cardiac
status.
• Document a woman’s level of exercise
performance (i.e., what level she can do
before growing short of breath and what
physical symptoms she experiences, such as
cyanosis of the lips or nail beds).
• Ask if she normally has a cough or edema
(it’s important that women with cardiac
disease always report coughing during
pregnancy because pulmonary edema
from heart failure may first manifest itself
as a simple cough).
• Documenting edema is also important
because the usual innocent edema of
pregnancy must be distinguished from the
beginning of edema from heart failure
(serious).
• An important difference is the usual edema
of pregnancy involves only the feet and
ankles but becomes systemic with heart
failure.
• It can begin as early as the first trimester,
and other symptoms such as irregular pulse,
rapid or difficult respirations, and perhaps
chest pain on exertion will probably also
be present.
• Be certain to record a baseline blood
pressure, pulse rate, and respiratory rate
in either a sitting or lying position at the
first prenatal visit; at future health visits,
always obtain these in the same position
for the most accurate comparison.
• Making comparison assessments for nail
bed filling (should be < 5 seconds) and
jugular venous distention can also be
helpful throughout pregnancy.
• If a woman’s heart disease involves right-
sided heart failure, assess liver size at
prenatal visits. Keep in mind that liver
assessments can become difficult and
probably inaccurate late in pregnancy
because the enlarged uterus presses the
liver upward under the ribs and makes it
difficult to palpate.
• For an additional cardiac status
assessment, an electrocardiogram (ECG) or
an echocardiogram may be done at
periodic points in pregnancy.
• Assure the woman that an ECG merely
measures cardiac electrical discharge and
so cannot harm her fetus in any way.
Echocardiography uses ultrasound and,
likewise, will not harm her fetus.
FETAL ASSESSMENT
• At the point that maternal blood pressure
becomes insufficient to provide an
adequate supply of blood and nutrients to
the placenta, fetal health can be
compromised.
• For this reason, the infants of women with
severe heart disease tend to have low birth
weights or be small for gestational age
because of acidosis, which develops due to
poor oxygen/carbon dioxide exchange or
not being furnished with enough nutrients.
• This can result in preterm labor, which
exposes the newborn to the hazards of
immaturity as well as low birth weight. If
the placenta is not filling well, a fetus may
not respond well to labor (evidenced by
late deceleration patterns on a fetal heart
monitor), and a cesarean birth may be
necessary (an increased risk for both the
mother and fetus).
NURSING DIAGNOSIS:
• Deficient knowledge regarding steps to
take to reduce the effects of maternal
cardiovascular disease on the pregnancy
and fetus
OUTCOME EVALUATION:
• Patient identifies danger signs such as
angina pain and steps to take when they
occur; maternal blood pressure is
maintained above 100/60 mmHg and
fetal heart rate at 110 to 160 beats/min.
14
• Be certain that goals and outcomes
established with a woman with heart
disease are realistic. Not all women with
heart disease, for example, will be able to
complete a pregnancy successfully; some
infants of women with severe involvement
will be born with the effects of placental
insufficiency, such as neurologic involvement
or cognitive challenge.
• However, there are positive actions a
woman with heart disease can take to
reduce or eliminate complications during
pregnancy, such as increasing periods of
rest to strengthen heart action.
NURSING INTERVENTIONS DURING
ANTEPARTAL PERIOD
PROMOTE REST
• As a rule, women with cardiac disease
need two rest periods a day (fully resting,
not getting up frequently) and a full night’s
sleep (not tossing and turning) to obtain
adequate rest.
• Rest should be in the left lateral recumbent
position to prevent supine hypotension
syndrome and increased heart effort.
• Women should plan activities so they stop
exercising before the point when cardiac
output becomes insufficient to meet
systemic body demands causing peripheral
and uterine/placental constriction. Be
certain they know exactly how much they
should limit their exercise.
PROMOTE HEALTHY NUTRITION.
• A woman with cardiac disease may need
closer supervision of nutrition during
pregnancy than the average woman
because she must gain enough weight to
ensure a healthy pregnancy and a healthy
baby, but she must not gain so much weight
that her heart and circulatory system
become overburdened.
• Be certain she is remembering to take her
prenatal vitamins. These contain an iron
supplement to help prevent anemia.
• Anemia is important to prevent because it
places an extra burden on the heart
because her circulatory system must
circulate blood more vigorously than usual
to distribute oxygen to all body cells.
• If a woman was following a sodium-
restricted diet before pregnancy, this may
be continued during pregnancy; although
typically, a woman’s sodium intake is only
limited, not severely restricted, during
pregnancy because it’s important to obtain
enough sodium to maintain fluid volume
and balance as well as furnish an
adequate supply of blood to the fetus.
EDUCATE REGARDING MEDICATION.
• Women taking cardiac medication, such as
digoxin, before pregnancy may need to
increase their maintenance dose because
of their expanded blood volume during
pregnancy. A woman who was not digoxin
dependent before pregnancy may need
such therapy prescribed as pregnancy
advances and her cardiac output has to be
increased or strengthened.
• To aid a woman in continuing to think of
herself as basically a well person, help her
to understand this does not mean her heart
function is weakening, but rather, it is only
temporarily being stressed by the
increased circulatory load of pregnancy.
• Digoxin also has a unique use during
pregnancy as it can be administered to the
woman to slow the fetal heart if fetal
tachycardia is present.
• Antihypertensive and arrhythmia agents
such as adenosine, â- blockers, and calcium
channel blockers to reduce hypertension
are safe to use during pregnancy and are
also frequently prescribed. Nitroglycerin, a
compound often prescribed for angina,
although not well studied during pregnancy
(a category C drug), is also considered
safe.
EDUCATE REGARDING AVOIDANCE OF
INFECTION.
• A systemic infection almost automatically
increases body temperature, forcing a
woman to expend more energy and
increase her cardiac output as her
metabolism increases, an effect that could
be too extreme for a woman with heart
disease to withstand.
• Caution women with heart disease,
therefore, to avoid visiting or being visited
by people with infections and to alert
healthcare personnel at the first indication
of an upper respiratory tract infection or
urinary tract infection (UTI) so that, if
warranted, antibiotic therapy can begin
early in the course of the infection.
• Monthly screening for bacteriuria with a
clean-catch urine test at prenatal visits
should help detect UTIs.
15
BE PREPARED FOR EMERGENCY ACTIONS.
• If women with heart disease overexert
during a prenatal visit, they may need
supplemental oxygen or cardiac
resuscitation. The rules for cardiac
resuscitation for women who are pregnant
do not differ from the usual technique
NURSING INTERVENTIONS DURING
INTRAPARTUM AND POSTPARTUM PERIODS
INTRAPARTUM PERIOD
• Frequently assess a woman’s blood
pressure, pulse, and respirations and
monitor fetal heart rate and uterine
contractions during labor for women with
heart disease to be certain their circulatory
system is not failing and the placenta is
filling adequately.
• A rapidly increasing pulse rate (.100
beats/min) is an indication a heart is
pumping ineffectively and so has increased
its rate in an effort to compensate.
Normally, it’s good to advise a woman to
assume a side-lying position during labor
to reduce the possibility of supine
hypotension syndrome.
• If a woman has some pulmonary edema,
however, it may be necessary for her to
elevate her head and chest (a semi-
Fowler’s position) to ease the work of
breathing.
• If this is necessary, be certain to place a
towel under her right hip to shift the uterus
off the vena cava, the same as would
happen with a side-lying position.
• Remember, fatigue is a symptom of heart
decompensation. Evaluate women
carefully, therefore, to determine whether
the fatigue a woman reports is heart or
labor related.
• Women with extreme heart disease may
need oxygen administered during labor
because of the need for extra oxygen due
to the exertion of labor
• Many women with heart disease should not
push with contractions, as pushing requires
more effort than they should expend.
• That makes epidural anesthesia the
anesthetic of choice for women with heart
disease because this decreases the
sensation of pushing and can make both
labor and birth less taxing.
• Because of the lack of pushing, low forceps
or a vacuum extractor may be used for
birth. A woman may be disappointed
during labor to learn her labor is not going
to be “natural.”
• Stress that these measures may not be
what she anticipated, but they can help her
achieve her ultimate goal, a healthy
newborn and a mother able to care for her
new baby.
POSTPARTUM PERIOD
• The period immediately after birth is a
critical time for a woman with heart
disease because, with delivery of the
placenta, the blood that supplied the
placenta is released into her general
circulation, increasing her blood volume by
20% to 40%.
• During pregnancy, the increase in blood
volume that occurred did so over a 6-
month period, so her heart had time to
gradually adjust to this change. After birth,
the increase in pressure takes place within
5 minutes, so the heart must make a rapid
and major adjustment
• To compensate for these circulatory
changes, a woman may need a program of
decreased activity and possibly
anticoagulant and digoxin therapy until
her circulation stabilizes.
• Antiembolic stockings or intermittent
pneumatic compression (IPC) boots may be
prescribed to increase venous return from
the legs. If prophylactic antibiotics had not
been started prior to birth, they should be
started immediately after birth to
discourage subacute bacterial endocarditis
caused by the introduction of
microorganisms through the placental site.
• A woman with heart disease is often
interested in close inspection of her baby
immediately after birth because she wants
to know if her infant has a heart defect or
was harmed by any medication she took
during pregnancy.
• Be certain to point out that acrocyanosis is
normal in newborns, so she does not
interpret her baby’s peripheral cyanosis as
cardiac inadequacy.
• In the postpartum period, a stool softener
can be prescribed to prevent straining with
bowel movements. Agents to encourage
uterine involution, such as oxytocin (Pitocin),
should be used with caution because they
16
 tend to increase blood pressure, which
necessitates increased heart action. As a
rule, women with heart disease can
breastfeed without difficulty.
• Kegel exercises are acceptable for
perineal strengthening immediately, but the
woman should not begin postpartum
exercises to improve abdominal tone until
her primary care provider approves them.
• Before discharge, be certain a woman has
thought through if she will need help at
home, so she can continue getting periods
of rest.
• Also ensure that she schedules a return
appointment for a postpartum checkup for
both her gynecologic health and her
cardiac status.
QUALITY AND SAFETY EDUCATION FOR
NURSES (QSEN)
• Patient-Centered Care
• Teamwork and Collaboration
• Evidence-based practice
• Quality improvement
• Safety
• Informatics
REDUCING RISK OF THROMBOEMBOLIC
DISEASE THROUGH QSEN
COMPETENCIES
• The incidence of venous
thromboembolic disease
increases during
pregnancy because of a
combination of stasis of
blood in the lower
extremities from uterine pressure and
hypercoagulability
• When the pressure of the fetal head at
birth puts additional pressure on lower
extremity veins, damage can occur to the
walls of the veins. With this triad of effects
in place (stasis, vessel damage, and
hypercoagulation), the stage is set for
thrombus formation in the lower
extremities.
• The likelihood of deep vein thrombosis
(DVT), formation of a blood clot in the veins
of the lower extremities, leading to
pulmonary emboli is highest in women 30
years of age or older because increased
age is yet another risk factor for
thrombosis formation
• The risk of thrombus formation can be
reduced through common-sense measures
such as avoiding the use of constrictive
knee-high stockings, not sitting with legs
crossed at the knee, and avoiding standing
in one position for a long period
• If a in the calf of a leg. It is diagnosed by
a woman’s history and Doppler
ultrasonography. In order to keep the
thrombus from moving and becoming a
pulmonary embolus, a woman will be
treated with bed rest and intravenous
heparin for 24 to 48 hours.
• After this, she may be prescribed
subcutaneous heparin she can self-inject
every 12 or 24 hours for the duration of
the pregnancy.
• It is generally recommended the lower
abdomen be used for rotating sites for
subcutaneous heparin administration. With
pregnancy, however, this site is usually
avoided and the injection sites are limited
to the arms and thighs. Heparin dosage is
regulated by the anti-Xa test, the most
accurate assay for monitoring
unfractionated heparin and low–molecular-
weight heparin
• The signs of a pulmonary embolism, such as
chest pain, a sudden onset of dyspnea, a
cough with hemoptysis, tachycardia or
missed beats, or dizziness and fainting
need to be recognized because it is an
immediate emergency and measures should
be immediately begun
• Caution women taking heparin during
pregnancy not to take any additional
injections once labor begins to help reduce
the possibility of hemorrhage at birth.
HIGH-RISK PREGNANCY: ENDOCRINE
SYSTEM
A WOMAN WITH DIABETES MELLITUS
• Diabetes mellitus is an endocrine disorder
in which the pancreas cannot produce
adequate insulin to regulate body glucose
levels. The disorder affects 3% to 5% of
all pregnancies and is the most frequently
seen medical condition in pregnancy
• It is increasing in incidence as more and
more obese adolescents develop type 2
diabetes
Diabetes During Pregnancy
• In type 1 diabetes, which, although
unproven, is probably an autoimmune
disorder because marker antibodies are
17
 present, the pancreas fails to produce
adequate insulin for body requirements
• In type 2 diabetes, there is a gradual loss
of insulin production, but some ability to
produce insulin will still be present.
• Women with either type 1 or type 2
diabetes who have successful regulation of
glucose and insulin metabolism before
pregnancy are apt to develop less-than-
optimal control during pregnancy because
all women experience several changes in
the glucose– insulin regulatory system as
pregnancy progresses.
• Infants of women with poorly controlled
diabetes tend to be large (>10 lb)
because the increased insulin the fetus must
produce to counteract the overload of
glucose he or she receives acts as a growth
stimulant.
• Hydramnios may develop because a high
glucose concentration causes extra fluid to
shift and enlarge the amount of amniotic
fluid.
• A macrosomic infant may create birth
problems at the end of the pregnancy
because of cephalopelvic disproportion.
• This, combined with an increased risk for
shoulder dystocia, may make it necessary
for infants of women with diabetes to be
born by cesarean birth.
• At the same time, she must guard against
hypoglycemia (i.e., lowered serum glucose
levels) and ketoacidosis caused by the
constant use of glucose by the fetus.
• If a woman has preexisting kidney disease
(revealed by proteinuria, decreased
creatinine clearance, and hypertension), the
risk of hypertension of pregnancy rises
markedly
ASSESSMENT
• Because diabetes is such a serious
complication in pregnancy, all women
should be screened during pregnancy for
gestational diabetes. A fasting plasma
glucose greater than or equal to 126
mg/dl or a nonfasting plasma glucose
greater than or equal to 200 mg/dl meets
the threshold for the diagnosis of diabetes
and does not need confirmation.
Monitoring a Woman With Diabetes
• A woman with diabetes (type 1 or type 2)
before pregnancy should meet with her
primary healthcare provider prior to
becoming pregnant; during this period, her
condition can be well regulated so that
hyperglycemia does not develop during
the early weeks of pregnancy, when the
tendency for congenital anomalies in the
fetus is highest.
• A woman should use a home test kit to
determine she is pregnant so she knows this
at the earliest possible time.
• A urine culture may be done each trimester
to detect asymptomatic UTIs as the
increased glucose concentration in urine
may lead to increased infection.
NURSING DIAGNOSIS
• Deficient knowledge related to a
therapeutic regimen necessary during
pregnancy
OUTCOME EVALUATION
• Patient states importance of careful
attention to nutrition, exercise, and home
monitoring of glucose levels during
pregnancy; describes nutrition and exercise
program; states intention to keep nutrition
and exercise constant.
EDUCATION REGARDING NUTRITION
DURING PREGNANCY
• Women with diabetes need to be aware
of how much carbohydrate they eat daily
by estimating the total carbohydrate each
anticipated meal will contain and then
administer a number of units of insulin prior
to that based on a predetermined insulin-
to-carbohydrate ratio. As children also
need to adjust insulin amounts to
carbohydrate ratios
• Dietary control, or maintaining an
adequate glucose intake so hypoglycemia
does not occur, may be extremely difficult
early in pregnancy because of nausea and
vomiting.
• In addition, a woman’s diet should be
certain to include a reduced amount of
saturated fats and cholesterol and an
increased amount of dietary fiber.
• Increasing fiber decreases postprandial
hyperglycemia and so lowers insulin
requirements.
• Women are extremely vulnerable to
hypoglycemia at night during pregnancy
because of the continuous fetal use of
glucose during the time they sleep.
18
• Urge a woman to make her final snack of
the day one of protein and a complex
carbohydrate (e.g., an egg and whole
grain toast, hummus and whole grain
crackers) to allow slow digestion during the
night.
• If a woman cannot eat because of vomiting
or nausea early in pregnancy or heartburn
in later pregnancy, she should immediately
notify her healthcare provider as she may
need temporary intravenous fluid and
glucose supplementation.
EDUCATION REGARDING EXERCISE DURING
PREGNANCY.
• Exercise is another mechanism that lowers
serum glucose levels and, therefore, the
need for insulin. If a woman begins an
exercise program for the first time during
pregnancy, she may notice excessive
glucose fluctuations at first.
• Therefore, it’s best if she begins her
exercise program before pregnancy, when
glucose fluctuation can be evaluated and
food and snacks adjusted accordingly
before a fetus is involved.
• With exercise, blood glucose levels
decrease because the muscles increase
their need for glucose, an effect which lasts
for at least 12 hours after exercise. If the
arm in which a woman injected insulin is
actively exercised, the insulin is released so
quickly that it can cause hypoglycemia. To
avoid this phenomenon, a woman should
eat a snack consisting of a protein or
complex carbohydrate before exercise
and should maintain a consistent exercise
program
THERAPEUTIC MANAGEMENT
• Because blood glucose levels near normal
help minimize the risk of maternal and fetal
complications, both women with gestational
diabetes and those with overt diabetes
need more frequent prenatal visits than
usual to ensure close monitoring of their
condition and that of the fetus
Insulin therapy
→ Needed by pregestational and gestational
diabetics who are uncontrolled with diet or
oral therapy. Necessary for the cells to
take glucose from the bloodstream
Blood glucose monitoring
→ Completed four times a day by the
patient. The patient pricks her finger and
uses a glucometer to determine her blood
glucose.
Insulin pump therapy
→ An insulin pump is an automatic pump with
thin tubing, which is placed subcutaneously,
most often on the woman’s abdomen. Insulin
is given through this tube and injection of
insulin is therefore eliminated.
→ A continuous rate (basal) of insulin is given
to the patient through the pump, and the
patient can program the
pump to give extra
doses as boluses prior to
meals or correctional
doses related to her
blood glucose values
after meals
Tests for Placental Function and Fetal Well-
Being
→ Monitoring of fetal well-being will be
individualized depending on the woman’s
overall health. Because women with
diabetes tend to have infants with a higher
than normal incidence of birth anomalies, a
woman will have a serum á-fetoprotein
level obtained at 15 to 17 weeks to assess
for a neural tube defect and an ultrasound
examination performed at approximately
18 to 20 weeks to detect gross
abnormalities.
→ A normal creatinine clearance rate
suggests a woman’s vascular system is
intact because kidney function is normal. By
default, this also implies uterine perfusion is
also adequate.
→ Placental functioning may also be assessed
by a weekly nonstress test or biophysical
profile during the last trimester of
pregnancy if a woman is in good control,
or a daily nonstress test if her regulation is
poor.
Postpartum Adjustment
→ During the postpartum period, a woman
who came into pregnancy with diabetes
must undergo yet another readjustment to
insulin regulation.
→ With insulin resistance gone, often she
needs no insulin during the immediate
postpartum period
19
HIGH-RISK PREGNANCY: RENAL AND
URINARY SYSTEM ASSESSMENT
A WOMAN WITH CHRONIC RENAL DISEASE
• In the past, females
with chronic renal
disease did not
reach childbearing
age or were
advised not to
have children
because of their
automatic high-risk
status during
pregnancy.
• Today, with
conscientious prenatal care, women with
chronic renal disease and even women who
have had renal transplants, can expect to
have healthy pregnancies and healthy
children
• Women with chronic renal disease need to
be monitored carefully during pregnancy
because their diseased kidneys may not
produce erythropoietin, a glycoprotein
necessary for red cell formation and so
they may develop a severe anemia
• Fortunately, synthetic erythropoietin is now
available and is safe to take during
pregnancy
• Because the glomerular filtration rate
normally increases during pregnancy, a
woman’s serum creatinine level (a measure
of kidney function that elevates when
kidneys are under stress) may be actually
slightly below normal during pregnancy or
may fall from a usual level of 0.7 mg/100
ml to about 0.5 mg/100 ml.
• Women with kidney disease who normally
have a serum creatinine level greater than
2.0 mg/dl may be advised not to
undertake a pregnancy in case the
increased strain on already damaged
kidneys leads to kidney failure.
• Many women with renal disease routinely
take a corticosteroid such as oral
prednisone at a maintenance level. This
drug therapy typically is continued
throughout pregnancy.
• Women with severe renal disease may
require dialysis to aid kidney function
during pregnancy
• With dialysis, there is a risk of preterm
labor, perhaps because progesterone is
removed with the dialysis. To prevent this
complication, progesterone may be
administered intramuscularly before the
procedure.
• If women are on a low-potassium diet to
avoid a buildup of potassium that
accumulates because their diseased
kidneys do not evacuate it well, they may
need a nutrition consultation to be certain
they can continue to avoid potassium yet
also eat a healthy pregnancy diet. They
also may need a great deal of emotional
support during pregnancy because they
are aware of the stress of pregnancy on
damaged kidneys. By being pregnant,
they are risking not only the life of the child
growing inside them but also their own life.
HEMATOLOGIC DISORDERS AND
PREGNANCY
• Hematologic disorders during pregnancy
involve either blood formation or
coagulation disorders
ANEMIA AND PREGNANCY
• Because the blood volume expands during
pregnancy slightly ahead of the red cell
count, most women have a pseudoanemia
in early pregnancy.
• This condition is normal and should not be
confused with true types of anemia that
occur as complications of pregnancy.
• True anemia is typically considered to be
present when a woman’s hemoglobin
concentration is less than 11 g/dl
(hematocrit <33%) in the first or third
trimester of pregnancy or when the
hemoglobin concentration is less than 10.5
g/dl (hematocrit <32%) in the second
trimester
Iron-deficiency anemia
• is the most common anemia of pregnancy,
complicating as many as 15% to 25% of
all pregnancies
A Woman With Folic Acid–Deficiency Anemia
• Folic acid, or folate or folacin, one of the B
vitamins, is necessary for the normal
formation of red blood cells in the woman
as well as being associated with preventing
neural tube and abdominal wall defects in
the fetus.
A WOMAN WITH SICKLE-CELL ANEMIA
• Sickle-cell anemia is a recessively inherited
hemolytic anemia caused by an abnormal
20
 amino acid in the beta chain of
hemoglobin.
• If the abnormal amino acid replaces the
amino acid valine, sickling hemoglobin
(HbS) results; if it is substituted for the
amino acid lysine, nonsickling hemoglobin
(HbC) results.
• An individual who is heterozygous (i.e., has
only one gene in which the abnormal
substitution has occurred) has the sicklecell
trait (HbAS).
• If the person is homozygous (i.e., has two
genes in which the substitution has
occurred), sickle-cell disease (HbSS) results
• With the disease, the majority of red blood
cells are irregular or sickle shaped, so they
cannot carry as much hemoglobin as
normally shaped red blood cells can.
When oxygen tension becomes reduced, as
occurs at high altitudes, or blood becomes
more viscid than usual, such as occurs with
dehydration, the cells clump together
because of their irregular shape, resulting
in vessel blockage with reduced blood flow
to organs.
• The cells then will hemolyze (i.e., be
destroyed), thus reducing the number
available and causing a severe anemia.
• Although the sickle-cell trait does not
appear to directly influence the course of
pregnancy, preterm birth, growth
restriction, miscarriage, or perinatal
mortality, rates tend to be higher for
women with the homozygous disease. At
any time in life, sicklecell anemia is a threat
to life if vital blood vessels such as those to
the liver, kidneys, heart, lungs, or brain
become blocked. In pregnancy, blockage
to the placental circulation can directly
compromise the fetus, causing low birth
weight and possibly fetal death.
HIGH-RISK: SUBSTANCE ABUSE
• Still births occur in 0.62% of pregnancies
alcohol consumption during pregnancy
causes a 40% greater likelihood
• Consuming three or more drinks per week
while pregnant can significantly increase
the chance of miscarriage
• Both smoking and exposure to second-hand
smoke increase chances of premature birth
• The chances of premature birth are directly
related to the number of cigarettes smoked
with heavy smokers having a much greater
risk, exposure to tobacco smoke in utero
increases the odds of still birth two fold
over children who were not exposed
• Cocaine use in pregnancy increases odds
of low birth weight to 3.66x that of a non-
user
HIGH-RISK PREGNANCY: HIV/AIDS
• Taking treatment properly during
pregnancy and breastfeeding will keep
your baby free of HIV
• During pregnancy HIV can pass through the
placenta and infect the fetus
• During labor and delivery the baby may
be exposed to the virus from a woman's
blood and other fluids when a woman goes
into labor the amniotic sac breaks or her
water breaks, once this occurs the risk of
transmitting HIV to the baby increases
• If you are pregnant and have HIV/AIDS,
there is a risk of passing HIV to your baby
it can happen in three ways: (1) during
pregnancy, (2) during childbirth especially
if it is vaginal childbirth in some cases the
doctor may suggest doing a caesarean
section to lower the wrist during childbirth
and (3) is during breastfeeding
• You can greatly lower the risk by taking
HIV/AIDS medicines these medicines will
also help protect the health of the
pregnant woman and most HIV medicines
are safe to use during pregnancy, they
don't usually raise the risk of birth defects
but it is important to talk with your health
care provider about the risks and benefits
of the different medicines
• Together you can decide which medicines
are right for you then you need to make
sure you take the medicines regularly
21
 NURSING CARE OF A FAMILY WITH AN ILL
CHILD
• keeping in mind that children are not just
small adults is important when evaluating
how children react to illness perceive an
illness or react to health care
• Their body images, for example, as
evidenced in their drawings, are different
from those of adults. They may have
difficulty telling which body parts are
indispensable and which are not (this is why
it is wise to talk to preschool and early
school-age children about “fixing” body
parts, such as tonsils, rather than “taking
them out”).
• Illness is potentially traumatic because of
the unknown and because of the pain and
discomfort that may be involved
CHILDREN CAN VISIT THE HOSPITAL TO
FAMILIARIZE THEM WITH EQUIPMENT
• Preparing for hospitalization involves
disseminating developmentally
appropriate information facilitating
communication and developing trusting
relationships with healthcare professionals
• many childhood illnesses such as febrile
seizures, appendicitis, poisonings, and
asthma exacerbations are acute making
advance preparation for hospital
admission impossible
• However, when hospitalizations such as
elective surgeries are scheduled advance
preparation is possible with programs such
as pre-operative orientation
• The preparations parents make for a child
obviously vary depending on the child's
developmental age and experiences
• Depending on the age of the child there
may be anxiety if the child is told about
and approaching hospitalization too far in
advance
• Conversely, few things are more
frightening for children than to hear a
conversation held as they enter a room or
to hear adults spelling out unknown words
• As a rule, therefore, children between two
and seven years of age should be told
about a scheduled ambulatory or inpatient
hospitalization as many days before the
procedure as the child's age in years
• For example, a two-year-old should be
informed two days before hospitalization,
a four-year-old four days before, and so
forth
• Children older than seven years of age can
be told as soon as the parents are aware
of it on the day of hospital admission
• It is important for you to ask the parents
what preparations they have done to
ensure the child and family accurately
understand the child's condition and
upcoming procedures
• Based on that, you can provide further
health teaching and clear up any
misunderstanding as necessary
• Many hospital sponsors hospital orientation
programs for children's groups or school
groups during which hospitalization is
discussed
• These programs are beneficial because
they lay a foundation for all children about
what to expect during a hospitalization,
then if they must be admitted on an
emergency basis they may not be so
frightened
• Programs are offered by nurses at the
hospital or on visits to children's groups or
schools
→ It provides guidelines for setting up
hospital tours or discussions for early
school-aged children
• Illnesses that require the attention of
healthcare professionals are outside the
usual occurrences of childhood, so most
children typically have little knowledge
about them. Helping a child and family
prepare for or adjust to such an
experience is a fundamental nursing role.
This role goes well beyond just providing
information on what to expect throughout
an illness. It involves providing emotional
support as well.
• Studies from the 1980s and 1990s found
that family visitation was associated with
lower anxiety levels among adult
postanesthesia care unit (PACU) patients,
and similar results have been found among
pediatric patients.
• The literature has repeatedly shown that
unrestricted visitation in healthcare settings
increases family satisfaction, improves
children’s morale, and can improve
communication among the staff, the patient,
and the family.
22
2020 NATIONAL HEALTH GOALS RELATED
TO ILLNESS AND HOSPITALIZATION OF
CHILDREN
• Increase the proportion of children with
special healthcare needs who have access
to a medical home from 47.1% to 51.8%
• Increase the proportion of children aged 0-
11 years with special healthcare needs
who receive their care in family-centered,
comprehensive, and coordinated systems
from 20.4% to 22.4%
• Increase the proportion of children aged 0-
11 years with special healthcare needs
who receive their care in family-centered,
comprehensive, and coordinated systems
from 20.4% to 22.4%
→ Nurses can help the nation achieve these
goals by helping reduce the stress of
hospitalization or health care so families
use preventive services to help children
stay well rather than to totally use
emergent or ill child care services
THE MEANING OF ILLNESS TO CHILDREN
• The response of children to illness depends
on their cognitive ability, past experiences,
and level of knowledge. It parallels
cognitive development.
• From early school age, children generally
know quite a bit about the workings of
their major body parts. As general
guidelines, early grade-school children are
usually able to name the function of the
heart, lungs, and stomach.
• However, children are not able to see the
body as a system until the age of 10 to 11
years.
• Younger children may think the cause of
illness is magical or that it occurs as a
consequence of breaking a rule.
• With this perspective, they may also think
getting well again is possible only if they
follow another set of rules, such as staying
in bed and taking medicine.
• By fourth grade, children are generally
aware of the role germs play in illness but
may be fooled by thinking that all illnesses
are caused by germs. Because of this, they
may see a passive role for themselves in
getting well because illness comes from
outside influences.
• At about eighth grade, children are able to
voice an understanding that illnesses can
occur from several causes, such as being
susceptible to chickenpox because they did
not get a vaccine. This understanding is due
to the formal logical stage that Piaget
described, where there is differentiation
between self and other.
• An illness in a child is a stress, especially if
it includes hospitalization. Knowing how
children of each age view illnesses affects
the planning of nursing care and influences
how explanations should be worded.
• For example, saying you are going to
“stick” a child for blood work could be
interpreted by young children as meaning
you are actually going to put a stick in
their arm. Saying a child will receive dye
for a test could be interpreted as meaning
the child will “die” during the procedure.
• Explanations of procedures can sound
confusing if words sound alike or have
double meanings (e.g., “drawing” as in
making a picture vs. “drawing” blood).
• Because of these distorted perceptions,
explanations of procedures do not always
relieve children’s stress.
DIFFERENCES IN RESPONSES OF CHILDREN
AND ADULTS TO ILLNESS
INABILITY TO COMMUNICATE
• Very young children do not have the
vocabulary to describe symptoms. Children
younger than 5 years of age have a great
deal of difficulty describing a headache.
• Dizziness and nausea can be equally
bewildering because young children do not
know the words to express these
phenomena.
• By the time children reach school age, most
can describe symptoms with accuracy. They
may intensify their concerns if they believe
someone expects symptoms to be more
serious. They may minimize symptoms if
they are afraid that an illness will interfere
with an activity they want to do; thus, it is
important to evaluate a child’s symptoms as
much by observation as by a child’s report.
• A crying, whining preschooler who is “just
not herself” probably has a symptom she
cannot describe. A school-age child who
guards her abdomen (i.e., keeps
abdominal muscles rigid) is in pain just as
23
 clearly as a child who verbalizes a source
of discomfort.
INABILITY TO MONITOR OWN CARE AND
MANAGE FEAR
• Adults who are ill often ask questions about
medications prescribed for them or
procedures they are scheduled to undergo.
• If a hospitalized adult knows he is to
receive a diuretic three times a day and
by 10 AM has not been offered it as yet,
he usually reminds someone of the
oversight. School-age and younger children
cannot monitor their own care this way
because they may not know which medicine
or procedures they
• In addition, children have fears that adults
do not experience. For example, by 8 to 9
months, the infant fears separation above
all else; the toddler and preschooler
enlarge their fears to include separation,
the dark, intrusive procedures, and
mutilation of body parts.
Nutritional Needs
• Children differ from adults in many ways.
In addition to psychological differences,
there are major physiologic differences in
the way illnesses affect children compared
with adults.
• Children have greater metabolic demand,
breathe in more air per pound of body
weight than adults do, have a higher
surface to body mass ratio, and are at
greater risk for insensible fluid loss when
they are sick.
• For example, children need more nutrients
(calories, protein, minerals, and vitamins)
per pound of body weight than adults
because their basic metabolic rate is
faster, and they must take in not only
enough to maintain body tissues but also
enough to allow for growth. The infant, for
example, requires 120 kcal/kg of body
weight per day; the adult requires only 30
to 35 kcal/kg of body weight per day. An
ill child who must limit food intake because
of nausea or vomiting, therefore, may
require hospitalization for intravenous
therapy, even though this might not be
necessary for an adult under the same
circumstances.
FLUID AND ELECTROLYTE BALANCE
• In the adult, extracellular water (the water
held in plasma and outside body cells)
represents approximately 23% of total
body water; in a newborn, extracellular
water is closer to 40%. This means that an
infant does not have as much water stored
in the cells as an adult and so is more likely
to lose a devastating amount of body
water with diarrhea or vomiting.
SYSTEMIC RESPONSE TO ILLNESS
• Because a child’s body is continually
growing, young children tend to respond to
disease systemically rather than locally.
• The child with pneumonia, for example,
may be brought to an emergency
department not because of a cough
(although the child may have one) but
because of accompanying systemic
symptoms such as fever, vomiting, and
diarrhea. In fact, nausea and vomiting
occur so frequently in children with any
type of illness that these symptoms do not
have the diagnostic value that they may
have in adults.
• Systemic reactions of these kinds can delay
diagnosis and therapy and can cause
increased fluid and nutrient loss,
circumstances that compound the initial
illness.
AGE-SPECIFIC DISEASES
• Most adults have achieved immunity to
common infectious diseases; children,
however, are very susceptible to illnesses
such as measles, mumps, and chickenpox.
• Febrile children between the ages 6 and
60 months who do not have an intracranial
infection or metabolic disturbance are
typically diagnosed with “febrile seizure”
PREPARING FOR HOSPITALIZATION
PREPARING FAMILY CAREGIVERS
• Planning for hospitalization should begin as
soon as parents know hospitalization will
be necessary. Some parents, however, may
be so concerned about the reason for
hospitalization that they cannot begin to
prepare their child until they are better
prepared themselves. Easing parental
concerns regarding illness and
hospitalization is particularly important
because children may be able to sense a
parent’s stress. Even though a parent says,
“Don’t worry, everything will be all right,”
a child can sense if parents really do not
believe everything will be all right.
PREPARING AN INFANT
• Because an infant cannot understand
explanations of surgery or treatments,
24
 verbal preparation is minimal. Remind
parents to pack special items such as a
favorite toy, blanket, or pacifier because
these objects provide a special kind of
security for which there is no substitute.
PREPARING A TODDLER OR PRESCHOOLER.
• Three chief fears of toddlers or
preschoolers are fear of the unknown, fear
of abandonment or separation, and fear
of mutilation. Preparation for children of
this age, therefore, should clearly aim at
alleviating these three fears.
• Bringing a favorite toy or personal item
such as a blanket can help. Referred to as
“transitional objects,” these items are
reminders about something familiar from
home.
• If hospitalization is to be more than 1 week
long, parents need to think about how their
child will continue schooling. Advise them to
ask their care provider at what point the
child will be able to do homework. Many
school systems provide tutors, and
children’s hospitals often have their own
teachers from the local school system to
carry out this service so children do not fall
behind due to hospitalization
PREPARING A SCHOOL-AGE CHILD OR
ADOLESCENT
• School-age children enjoy reading and
visual media; thus, books or videos about
surgery and hospitalization can be helpful
for preparation. Be sure both school-age
children and adolescents receive factual
explanations of what will happen during
surgery. If parents do not have enough
information to be able to answer a school-
age child’s questions, remind them that few
people know everything and caution them
that their best response may be “I don’t
know, but I will find out.”
PREPARING A CHILD WITH A DIFFERENT
CULTURAL BACKGROUND
• Perhaps the most important aspect to
consider when preparing a child from a
different culture for hospitalization is to
identify if there are traditions or practices
that will be in opposition to usual
healthcare facility practices. Ask enough
questions and practice good listening skills
to gain information about the particular
needs of a child and his or her family.
• When cultural differences do exist, be
prepared to act as a liaison between the
family and the healthcare team. If a
different language is interfering with
communication, a medical translator may
be necessary in this preparation phase.
Provide the opportunity for parents to
voice their fears and ask questions and
allow time and opportunity for discussion
and effective communication.
PREPARING A CHILD WITH UNIQUE
CONCERNS OR WHO IS CHRONICALLY ILL
• Children with unique physical concerns or
those who are chronically ill frequently
come to ambulatory healthcare settings for
care; they also are often admitted to the
hospital for care and possibly remain in the
hospital for an extended time followed by
continuing care at home.
• Children with chronic illness are likely to
have been admitted to the hospital in the
past, draw upon past experiences, and
may be able to let you know how they like
certain things.
• A child with a chronic illness is still at risk
for the same type of anxiety that a child
with an acute illness requiring
hospitalization has.
• To decrease anxiety, help children to
maintain contact with their families and
school friends during a long hospitalization
by encouraging telephone calls, social
media use, e-mails, text messaging, letters,
and visits.
SEPARATION EFFECTS
• PROTEST: a time during which the child
cries loudly and demandingly
• DESPAIR: A time when the child acts
depressed and withdraws from parent and
healthcare providers
• DETACHMENT: A time during which the
child becomes more interested in
surroundings than in visitors; coping
mechanism only, not sign of acceptance of
separation from parent
ADMITTING THE ILL CHILD AND FAMILY
• Whether an ambulatory or inpatient
hospital unit admission, children and
parents need to be admitted as a single
entity to encourage parents to feel that
they are true partners in care.
• A child coming to a hospital for an elective
admission generally arrives at a reception
area where demographics are obtained,
such as name, age, address, and hospital
25
 insurance coverage. The child and parents
are then brought to the hospital unit.
• Remember that first impressions count. If
parents are left standing at a counter
without being addressed, they can easily
feel that no one appreciates their concern
and that possibly their child will not receive
optimal care.
• Introduce yourself, explain your role to the
parents and child, and find a comfortable
place for the family to wait until someone
is available to orient them to the unit.
When introducing yourself to children,
stoop down so that your face is level with
the child’s face. Call the child by his or her
name or ask for a nickname.
• All children should have an armband
attached which lists their name, date of
birth, and hospital medical record number.
Because their hands are not much larger
than their wrists, and their feet are not
much larger than their ankles, small infants
often need two bands in place as an extra
safeguard. If a band should fall off, verify
the patient’s identity using at least two
patient identifiers (acceptable identifiers
may be the individual’s name, an assigned
identification number, telephone number, or
other person-specific identifier) and secure
it back onto the child; never tape it to the
crib or bedside stand because this will not
properly identify the patient, and the child
could be given a wrong medication or
have an unintentional procedure.
NURSING PROCESS: AN ILL CHILD
NURSING DIAGNOSIS
• Deficient knowledge related to
preparation for hospitalization
• Parenteral and child anxiety related to the
need for the child’s hospitalization
• Anxiety of child related to separation
during hospitalization
• Fear related to diagnostic or therapeutic
procedures
• Parental health-seeking behaviors related
to care for child at home after hospital
discharge
• Risk for delayed growth and development
related to the effects of illness
• Risk for imbalanced nutrition, less than
bodily requirements, related to lack of
appetite
• Risk for injury related to procedures or
therapy necessary for care
• Disturbed sleep pattern related to timing
of medications, discomfort, or sleep
disorder
• Deficient diversional activity related to lack
of appropriate toys and peers
PROMOTING A POSITIVE HOSPITAL STAY
• Several nursing actions lay an important
foundation for creating a successful, rather
than an unsuccessful, hospital experience
PROVIDING CONTINUITY OF CARE
• Minimizing length of stay
• Providing continuity of care
• Decreasing separation anxiety
• To ensure that children are exposed to as
few caregivers as possible and to maintain
the consistency and quality of care, nursing
assignments are best if one nurse gives as
much care to the same child as possible
(primary nursing)
• “Primary nursing promotes ongoing
communication between the patient, family,
nurses, and physicians by building rapport
and facilitating discharge planning
beginning on admission.
• These staffing patterns allow the same
nurse to admit the child, take the nursing
history, establish nursing diagnoses, set
goals for care in cooperation with the
parents and the child, and evaluate
progress toward achieving goals.
• It allows children to have one main nurse to
call their own. It is also helpful to parents
because it allows them to establish a
meaningful contact with the hospital staff
and maintains continuity of care, planning,
and implementation.
→ Promoting visitation
→ Encouraging parents to participate
→ Supporting sibling and grandparent
visitation
→ Minimizing negative effects of procedures
→ Reducing or eliminating pain
 One nurse who is “theirs" can minimize
separation anxiety
Maintaining child’s bed as safe area
• is to assure children that their bed is an
area that is safe all painful procedures
26
 should be done in a treatment room or
another department away from the child's
bed
• Decreasing painful procedures at the
bedside promotes a child's feeling of
safety
• Remember that finger punctures for blood
work although done quickly can cause as
much pain and stress as a venipuncture
• In addition, dressing changes although not
necessarily painful can cause worry and
also should be done in a treatment or
procedure room when applicable
HELPING CHILDREN MAINTAIN CONTROL
• Helping Children Maintain Control. Events
are always more frightening if they seem
to be beyond our control. Based on the
child’s developmental age, explaining to
children what will happen, including what
they will feel or what they will see, and
helping them to make choices whenever
possible limits this type of fear because
these actions offer a sense of control
PROVIDING ADEQUATE PLAY FACILITIES
• Play is often described as the work of
children because it is the medium through
which they learn. Play is often an indicator
of how the child is coping with the stressors
of hospitalization and may act as way to
control their environment
• Therapeutic play is play designed to help
children express their feelings about
painful or frightening procedures however,
play needs are different for each child.
SETTING LIMITS ON BEHAVIOR
• Setting limits on behavior can help promote
a positive hospital stay because it can help
to provide a sense of security and safety.
Children who refuse to cooperate for
procedures generally do so out of fear of
the unknown rather than deliberate
misbehavior. The better prepared a child is
for a procedure, the more apt the child is
to accept it
DISCHARGE PLANNING
• Discharge planning is not only an important
link between the hospital and the home, but
it is also a final way to create a satisfying
hospital experience.
PROMOTING ADEQUATE SLEEP
• Promoting Adequate Sleep for the Ill Child
Ill children need adequate rest and sleep
so their body tissues can effectively use
nutrients for repair and normal growth can
continue
• Children may not sleep well when they are
ill because of discomfort, pain, the
administration of medications, or intensified
symptoms of chronic sleep problems. They
may not sleep well in a hospital because it
is a strange setting; they may have to
undergo so many procedures that they also
do not nap or rest as much during the day
as usual. Children who are recovering from
trauma such as injuries from a car accident
or burns may be unable to sleep because
of nightmares about the accident.
27
• These nightmares can cause them to suffer
sleep deprivation in the same way as a
child who is frequently awakened for
procedures during the night. Encourage
parents to stay with these children for
support and comfort.
• Remember, though, that parents who sleep
in hospital rooms do not obtain adequate
sleep either. Although their presence is
healthy for children, it can limit the parents’
capacity to meet the child’s needs
(A) A normal sleep pattern. Notice how the
periods of rapid eye movement (REM)
sleep increase in length during the last half
of the night.
(B) The sleep pattern of a child who has been
awakened frequently during the night.
Notice how little REM sleep is present.
SLEEP PATTERNS
• Sleep is influenced by apprehension level,
state of health, habit, medication, and
environment at the time of sleep. As a
sleep cycle begins, children first enter non–
rapid eye movement (NREM) sleep. This
type of sleep occurs in up to 80% of total
sleep time. As children fall deeper and
deeper asleep, they pass from stage I to
stages II, III, and IV of NREM sleep over a
period of 20 to 30 minutes.
• Rapid eye movement (REM) sleep follows.
In infants, most of sleep time is REM sleep,
whereas late adolescents have the least
amount of this type of sleep. The sleep
pattern of a child who is awakened
frequently during the night for procedures
would resemble
• The purpose of NREM sleep, the first phase
of sleep, is rest and restoration of the
body; this stage keeps body cells
functioning and healthy.
PROMOTING ADEQUATE STIMULATION FOR
THE ILL CHILD
• Children are in constant interaction with
both their internal environment (body) and
their external environment (surroundings)
by means of their five senses and the
central nervous system. This makes them
capable of responding to changes in the
environment and, by so doing, meets basic
needs.
• Any illness that changes their ability to
respond to their environment can cause
either sensory deprivation or sensory
overstimulation
SENSORY DEPRIVATION
• Sensory deprivation is the condition of
being deprived of, or lacking, adequate
sensory, social, physical, or cognitive
stimulation.
• When this happens, children tend to lose
the ability to make decisions and become
easily confused and depressed. Some
children are more prone to sensory
deprivation than others.
• Ill children may have sensory deprivation
because they are confined to their homes
or hospital rooms and their varied activities
such as school, sports, and clubs are
replaced with hours of watching television
or playing video games.
PROVIDING STIMULATION FOR THE CHILD
ON BED REST
• Children on bed rest cannot secure
materials for cognitive stimulation by
themselves or participate in physical
activities, except to a limited degree. A
room where walls and windows offer no
visual appeal and therapeutic equipment
provides the only sound offers them little
sensory stimulation. If no one comes into the
room, they may suffer from social
deprivation. When possible, encourage a
child with restricted mobility to move out of
bed into a wheelchair; this can provide
some mobility and transportation to a
place of interest, such as near a window or,
in a hospital, near the nurses’ desk.
PROVIDING STIMULATION FOR CHILDREN
ON TRANSMISSION-BASED PRECAUTIONS.
• Children who are placed on transmission-
based precautions because of the
possibility of contagious illness may
experience severe sensory deprivation if
everyone who enters the room must wear a
gown and mask or if the number of visitors
must be kept to a minimum.
28
• If gloves are part of precautions, a child
can experience a significant loss of skin-to-
skin contact as well.
• Careful planning must be done to ensure
that a child who is isolated this way is not
psychologically isolated and that every
possible measure is carried out to maintain
sensory, social, physical, and cognitive
stimulation.
• Providing safe, reliable Internet resources
for immunosuppressed adolescents with
chronic conditions wanting to socialize with
peers can be an alternative to direct
socialization and also decreases the risk of
contracting a communicable illness
SENSORY OVERLOAD
• Sensory overload, in contrast to
deprivation, occurs when children receive
more stimulation than they can tolerate or
process. Children with sensory overload
react similarly to those with sensory
deprivation or feel confused, unable to
make decisions, and feel severely fatigued.
• Sometimes, it is difficult to determine the
cause of these symptoms (whether they are
caused by sensory deprivation or
overload) unless assessed carefully.
PROMOTING PLAY FOR THE ILL CHILD
• Play, often described as “the work of
children,” is an invaluable component of
child health care. Providing a space and
opportunity for play can help children feel
more comfortable and allow for an
important release of energy for children
who are confined to a room or bed.
• Play also may be used to help assess
children’s level of knowledge and feelings
about their condition so that more
individualized nursing care can be
planned. Depending on a child’s age, play
can also be a useful tool in health teaching
• Children enjoy making friends with other
children, talking to other children in nearby
beds, and being in the playroom where
they can talk to and get to know other
children
• Defining play is not a simple task because
play activities vary greatly from child to
child and among different developmental
age, cultural, and socioeconomic groups. A
common definition is that play is any
voluntary activity engaged in for the
purpose of enjoyment.
• If a child views an activity as enjoyment,
therefore, no matter what it is and whether
it would be fun or not for an adult, it is
play.
→ Assessing health through play
→ Play in ambulatory settings
→ Play in hospital
→ Play for children on bed rest
→ Safety with play
→ Child support programs
THERAPEUTIC PLAY
• Because play is the language of children,
children who have difficulty voicing their
thoughts in words can often speak clearly
through play. Play that involves specialized
activities that are developmentally
supportive and facilitate the emotional
well-being of a pediatric patient is
considered therapeutic play. It should be
noted that therapeutic play and play
therapy are different. Play therapy
addresses basic and persistent
psychological issues associated with how a
child may interact with his or her world
• For therapeutic play, only the child’s verbal
cues are used as responses.
• Therapeutic play can be divided into three
types:
1. Energy release - Children release
energy by pounding, hitting, running,
punching, or shouting.
2. Dramatic play - Dramatic play is
acting out an anxiety-producing
situation. It is most effective with
29
 preschool children because they are at
the peak of imagination.
3. Creative play - Some children are too
angry to be able to act out their
feelings through dramatic play.
However, they may be able to draw a
picture that expresses their emotions or
conveys the extent of their knowledge.
To encourage this, give a child a blank
paper and crayons or markers. If a
child seems reluctant to draw
something spontaneously, suggest a
topic: “Why don’t you draw a picture
of yourself?
• A conference with healthcare team
members, including a psychologist or a
psychiatric nurse specialist, may be needed
if a child continues to express mutilating
behavior after normal reassurance.
QSEN
• Patient-centered care
• Teamwork & Collaboration
• Evidence-Based Practice
• Quality Improvement
• Safety
• Informatics

GUIDELINES FOR CONDUCTING

THERAPEUTIC PLAY
• Use common sense when conducting
therapeutic play. For example, try not to
interpret a child’s black and gloomy
drawing as meaning the child is depressed
when a black marker was the only one
available.
• Many children 4 to 5 years of age draw a
person lacking many body parts because,
from a developmental standpoint, that is
how they start to draw (usually just a head
and no body, with lines representing arms
and/or legs coming out of the head).
• Remember, too, that all children
occasionally treat dolls badly. A 2-year-
old who pounds and bangs a rag doll may
not be expressing anger toward the doll
image at all but may be intent on
discovering the feel of a new texture and
is unaware for the moment that the object
is a doll.

30
 NURSING CARE OF A FAMILY WHEN A
CHILD NEEDS DIAGNOSTIC OR
THERAPEUTIC MODALITIES
• Illness can be particularly stressful if many
diagnostic and therapeutic procedures are
necessary for care as everything that
nurses do with
• For ill children can have a major influence
on a child's progress toward health as well
as on the child's and family's perception of
professional health care and the ability to
carry out helpful practices in the future
even more interventions are needed
ASSESSMENT
• Before performing procedures such as
assisting with a diagnostic test or collecting
laboratory specimens, first carefully
evaluate a child’s age and developmental
stage as well as any special needs a child
may have. Even the most common and
painless procedures create a certain
amount of stress for children and parents.
• During complex diagnostic procedures, this
stress level is almost certain to increase
even further due to fear of the unknown.
Unfamiliar people (e.g., doctors, nurses,
other health team members), high-tech
supplies and equipment, and strange
surroundings all add up to a frightening
experience for most adults; imagine how
frightening they are to children.
→ Carefully evaluate a child’s age and
developmental stage, as well as any
special needs
→ Assess a child’s level of anxiety
NURSING RESPONSONSBILITIES WITH
DIAGNOSITC AND THERAPEUTIC
MODALITIES
OBTAINING INFORMED CONSENT
• Informed consent is a process in which the
healthcare provider discloses or explains a
proposed medical treatment, along with
the risk(s), benefit(s), and alternative(s) for
that treatment. Informed consent is legally
required and must be obtained before any
procedure or treatment that has a risk of
causing injury to the child is performed.
Each procedure or treatment must have a
documented consent. The benefits and risks
of the treatment or procedure must be
discussed along with the risks if the
treatment or procedure was not
performed.
• Although obtaining consent is the provider’s
responsibility, ensuring that it is obtained is
a nursing responsibility.
EXPLAINING PROCEDURES
• To be able to explain procedures clearly
and answer questions about them
appropriately, try to observe as many
procedures as you can. After any
procedure, asking children to describe
what sensations they experienced can help
them work through possibly frightening
situations (often called “debriefing”) and
can also increase your knowledge of
common procedures.
• As a general guide, before a procedure, a
child needs a detailed description of what
to expect, such as “I’ll clean your finger.
You will feel a small pinprick”
→ Why the procedure is being
performed (e.g., “Your doctor needs
to look at your blood to see why
you’re so sick”)
→ Where the procedure will be done
(e.g., the X-ray department, a
treatment room)
→ Any unusual sensations to be expected
during the procedure (e.g., “The
alcohol I use to clean your skin will
feel cold”)
→ Any pain involved (e.g., “The needle
will sting, although I’ll put some cream
on first to dull the feeling”)
SCHEDULING
• If a child is having more than one
diagnostic procedure in a day, try to
arrange for the child to have time for
meals and some free play time between
the procedures.
• If food or fluid must be restricted, monitor
the child’s degree of discomfort and
physiologic needs related to the restriction.
• Advocate as necessary for sufficient
periods of time between examinations so a
child can eat or for decreased time
between procedures so the time spent
without food or fluid is limited.
PREPARING A CHILD AND FAMILY
PHYSICALLY AND PSYCHOLOGICALLY
• Physical preparation varies with each
procedure to be performed. In many
instances, preparing a child for an
examination, such as a barium enema,
involves another procedure such as a saline
enema, so that physical preparation also
31
 becomes education for the actual
examination. In all instances, explain both
the preparative and actual procedures and
allow the child to ask questions because
appropriate explanations aid in reducing
anxiety and fear
• Before a procedure, children may be given
an anxiolytic, such as midazolam (Versed),
to both relieve apprehension and allow
them to be mildly sedated. For painful
procedures or those that demand extreme
cooperation, such as a bronchoscopy or
closed fracture reduction, children may be
administered moderate sedation. Used in
both ambulatory and inpatient settings,
moderate sedation results in a depressed
level of consciousness induced by the
intravenous administration of a sedative
such as midazolam in combination with a
dissociative anesthetic, such as ketamine. It
is administered by an anesthesiologist, a
physician, or a nurse specially prepared in
the technique.
ACCOMPANYING THE CHILD
• Parental presence is essential when a child
is undergoing a procedure because it
reduces the child’s stress. However, if the
parents are unable to be present during a
procedure, allow them to remain close by,
such as a waiting room, so that they can be
called once the procedure is completed.
Ideally, a nurse whom the child knows
should accompany the child to the
procedure and remain with the child
throughout the procedure, or at least until
the child has met a primary person who will
be responsible for the procedure. Check
for any medication or specific baseline
assessment procedures such as vital signs
that should be performed before leaving
the unit for another department, in case the
child will be away from the primary unit
for an extended time. If there will be a
considerable wait in another department,
ask children if they would like to bring
along an activity such as a game or book.
In addition, hallways can be cool.
PROVIDING SUPPORT
• Children do well with diagnostic and
evaluative procedures as long as they have
adequate support from a familiar provider
or parent with them. Try to provide support
both verbally (i.e., explain what is going to
happen in age-appropriate terms) and
nonverbally (e.g., a hand on the arm or a
nearby presence).
MODIFYING PROCEDURES ACCORDING TO
A CHILD’S AGE AND DEVELOPMENTAL
STAGE
• It is important to consider a child’s age and
potential understanding of procedures
when planning the number and order of
tests and the way they will be performed.
THE INFANT
• The number of painful or uncomfortable
procedures done on infants should be kept
to an absolute minimum to avoid interfering
with an infant’s developing sense of trust.
• Advocate for parents to remain during
procedures to offer support. Some parents
may ask to hold their child during a
procedure that causes pain, but do not ask
parents to restrain the child during such a
procedure. Their role should be supportive
and comforting, not one that causes pain
• Diagnostic tests/procedures are kept to a
minimum
THE TODDLER AND PRESCHOOLER
• Toddlers and preschoolers resist any
diagnostic testing that involves any degree
of discomfort or pain or any procedure
that is unfamiliar to them.
• Give children of this age short explanations
of what to expect close to the time of the
procedure so that little time can be spent
worrying.
THE SCHOOL-AGE CHILD AND ADOLESCENT
• School-age children are concrete thinkers
and so are interested in the theory and
reason for procedures. They can often be
persuaded to cooperate for a procedure
by being promised a look at their X-ray or
a point-of-care meter readout afterward.
Be careful, however, to ensure that viewing
the results is actually possible before
promising this to children; otherwise, it can
be difficult to obtain any further
cooperation.
ADOLESCENT
• Project an air of maturity or sophistication
beyond their years
• They appreciate an explanation or a
comforting hand on a shoulder during a
procedure
USE OF RESTRAINTS
• The purpose of a restraint (physical or
chemical) during a procedure is to keep a
child safe from injury.
32
• Whenever possible, healthcare providers
should use alternative means of keeping a
child safe.
• Child has difficulty differentiating restraint
and punishment, restraint should never be
used more often or for any longer a time
than necessary
• Explain to parents…For example because
of a particular danger of this procedure it
is safer for their child
• Check restraints every 15 minutes…to see
if they are not occluding the circulation
→ Patients who are restrained must be
continuously monitored in accordance
with federal, state, and regulatory
agency guidelines. No part of a child’s
body other than that which is necessary
should be restrained. When infants have
scalp vein infusions in place, such as for
injection of a radioactive isotope for a
nuclear medicine scan, for example, their
arms may need to be immobilized so
they do not touch the infusion site. Their
trunk may need to be immobilized so
they do not turn. Their lower extremities,
however, do not need to be restrained so
they can still actively kick and exercise.
When a nurse or a parent is with a child,
in most instances, all restraints can be
removed.
TYPE OF RESTRAINT
1. WHEELCHAIRS & CARTS
→ Promote safety while
transporting children to
and from a healthcare
facility procedure department. For a
wheelchair, use a vest restraint. Attach
straps to the frame of the wheelchair
with enough slack so the child has some
mobility. For a cart, fasten a restraining
belt and raise the side rails.
2. CLOVE-HITCH RESTRAINTS
→ Secure one arm or
leg for a
procedure, such as
an intravenous
infusion.
→ Use disposable restraints, gauze, or soft
muslin tape. Soft muslin tape “gives” a
little if the child exerts pressure against it
so it will not pull too tight and reduce
circulation or cause pain.
→ If a child struggles against restraints, fold
several layers of soft gauze around the
wrist or ankle under the restraint. Secure
the restraint to the underpart of the bed.
Never tie restraints to side rails; when a
side rail is lowered, it will jerk the child’s
arm or leg and possibly cause an injury.
3. JACKET RESTRAINTS
→ Restrain children younger than
6 months in a supine position.
Fasten the ties at the back of
the jacket. Tie strips attached to
the sides of the jacket under the
mattress to keep the child in one position
4. ELBOW RESTRAINT
→ Prevent children from
touching the head or face
(e.g., following facial
surgery).
→ Use double layered piece of soft muslin
which has packets wide enough to fit
tongue depressors
→ Place pockets vertically, wrap restraint
around the child's arm then secure
restraint with ties, tape, or pins.
→ It may be necessary to pin restraint to
the child's undershirt to prevent slippage.
→ Assess the infant’s fingers to ensure the
sleeve is not too tight that it interferes
with circulation
5. MUMMY RESTRAINT
→ Temporarily
immobilize
young children
for a procedure
involving the
head, neck, or
throat (e.g., during insertion of a
nasogastric tube or blood drawing).
WHAT ARE COMMON DIAGNOSTIC
PROCEDURES?
ELECTROCARDIOGRAM (ECG)
• A test that checks for problems with the
electrical activity of the heart
• Checks rate and regularity of heartbeat
• You have to be very careful in teaching
children or having them have this
procedure because they have been
warned not to play with electric wires and
they worry about being burned or
electrocuted
→ Reassure electricity passes from their
body to the machine
→ Painless
33
 → (electrodes) Attached to the body by
paste
→ Give a test strip as souvenir
ELECTROENCEPHALOGRAM (EEG)
• An electroencephalogram (EEG) is a test
that measures and records electrical
activity of the brain.
• Special sensors (electrodes) are attached
to head and hooked by wires to a
computer.
• The computer records the brain's electrical
activity on the screen or on paper as wavy
lines
• Identify seizures, coma and dementia
XRAY STUDIES
• A variety of X-ray studies are used to
inspect internal aspects of the body, such
as bony structures. These range from simple
flat-plate views to more complicated
computed tomography scan or studies using
contrast dye.
Flat-Plate X-Rays
→ X-rays are used to diagnose and evaluate
the progress of illnesses as well as assess
the placement of apparatuses such as
gastrointestinal feeding tubes.
→ Parents are not allowed to stay in the room
→ If necessary, use lead apron and lead
glove
→ As a rule, children accept X-rays without
protest because the X-ray machine can be
compared with a camera, an instrument
with which they are familiar
DYE CONTRAST
• To visualize a body cavity, radiopaque
dye may be swallowed, instilled by enema,
or administered intravenously and then
revealed by X-ray.
• Areas to be examined are GI Tract
(Barium contrast study), kidney, etc
• Caution the child who is asked to drink
barium for a gastrointestinal study that
even if flavored, it does not taste terribly
good
→ Route: Oral, IV
→ Medium: A dye – iodine (may cause
allergic reaction), flavored yet has
terrible taste
→ Warn for hot flush
→ Use the word medicine instead of the
word “Dye”
• Children easily grow bored during this
procedure, have child take along an
activity to exam room to make time pass
faster.
• Try not to use the word dye when
describing a contrast medium to prevent
young children from worrying they will be
dyed like an Easter egg or will die. Use the
phrase special medicine instead
COMPUTED TOMOGRAPHY (CT SCAN)
• A painless, sophisticated x-ray procedure
• Multiple images are taken
• A computer compiles them into complete,
cross-sectional pictures (“slices”) of soft
tissue, bone and blood vessel
• As with any X-ray, dense structures appear
white and less dense structures appear
gray to black on the films.
• The procedure may include injection of an
iodine-based radioisotope contrast
medium. If this is necessary, the study may
be referred to as positron emission
tomography (PET) or single-photon emission
computed tomography (SPECT).
• It’s important for children to lie still during
the procedure to avoid creating artifacts
on the film. Sedation may be needed to
aid in the procedure.
MAGNETIC RESONANCE IMAGING (MRI)
• Combines magnetic field, radiofrequency,
& computer technology to produce
diagnostic images that aid in diagnosis of
disorders such as the cause of renal or
brain pathology
• May show problems that cannot be seen
with other imaging
• The child lies on moving pallet, pushed into
core of machine or magnet
• When Magnetic field surrounding child is
turned on, it causes tissue atoms to line up
in a parallel fashion.
• As radio waves are turned on and off,
atoms change position.
• This change is sensed and converted into
visual display on computer screen.
• This procedure has an advantage over x-
ray in that it has no apparent ill effects it
can reveal astonishingly clear structural
defects in soft tissue and if a contrast
medium is required it is not iodine based,
the danger of a reaction is minimal
• Because metal may deflect the magnetic
waves, children with a metal prosthesis or
metal dental braces are poor candidates
for the procedure.
34
• Hairpins and eye makeup (which often has
a metallic base), watches, or other jewelry
should be removed.
• Remove any metal from the child’s hospital
gown, which may include metal snaps.
• When the radio waves are turned on and
off during the procedure, a booming noise
can be heard. Prepare children for this
sound (which is often compared with the
sound of drums) as well as the feeling of
claustrophobia they may experience.
• Because the total procedure (excluding
cranial examinations) may take up to 45
minutes, sedation may be indicated so they
can lie quietly for this length of time
• Special care for children undergoing MRI
→ It has no apparent ill effects
→ It can reveal astonishingly clear structural
defects in soft tissue
→ Not iodine-based, so the danger of a
reaction is minimal
→ Metal may deflect the magnetic waves
RADIOGRAPHS (X-RAY)
• A projection of the chest used to diagnose
conditions affecting the chest, its contents,
and nearby structures
ULTRASOUND
• A painless procedure in which pictures of
internal tissue & organs, such as the
appendix, are produced by sound waves.
• Because it is noninvasive, children accept
ultrasound easily and may even enjoy
watching the oscilloscope screen during the
procedure.
• Compare the transducer that is used on the
body surface to pick up internal images to
a television camera so it is not viewed as
something strange
• Because ultrasound appears to have no
long-term effects, it can be repeated over
and over for serial determinations.
• Alert a child that the clear gel, which is
applied to the skin over the body part to
be studied, may feel cool and sticky.
NUCLEAR MEDICINE STUDIES
• Radiopharmaceuticals are radioactive-
combined substances that when given
orally or by injection, flow to designated
body organs.
• When a scintillation machine is passed over
the organ where the radiopharmaceutical
has collected, the pattern of the collected
material outlines the organ.
• The pattern can then be reproduced as a
screen image or a photograph.
• Parents may worry that a child will be
harmed by exposure to a radioactive
substance, and although this procedure
exposes the patient to low levels of
ionizing radiation, the risk is minimal when
used judiciously.
→ A danger of iodine is that it will go
immediately to the thyroid gland when
injected intravenously with the result that
enough concentrated radioactivity could
accumulate to destroy the thyroid gland
→ For this reason a blocking agent such as
potassium perchlorate that prevents
thyroid gland accumulation may be given
prior to the test this will help prevent the
radioactive substance from concentrating
in the thyroid thereby protecting the
gland
DIRECT VISUALIZATION PROCEDURES
• Involve the observation of an internal body
cavity by way of a thin tube inserted
through a body surface opening
• Types:
→ Endoscopy
→ Bronchoscopy
→ Colonoscopy
ENDOSCOPY
• Endoscopy involves the use of an
endoscope, which is passed through the
mouth, to examine the gastrointestinal tract
and has become a common method of
diagnosis for gastrointestinal disorders in
children.
• The procedure is also used as an
emergency measure to remove foreign
objects such as quarters or toys swallowed
by children.
• The thought of having a tube passed down
the throat can be very frightening. Even
after children understand what the
procedure will consist of, they can still be
very uncomfortable at the thought of a
tube being passed into them.
• Before the procedure, children must remain
on an NPO status for between 4 and 6
hours
They will need a sedative or moderate
sedation so they can lie quietly for the time
required.
35
• Good support during both the anxious time
waiting for the procedure and during the
procedure is crucial.
• Ask whether the child can have a digital
photograph taken during the procedure to
keep as a scrapbook souvenir.
After Care:
• Because the endoscope is passed through
the throat, edema of the throat may occur
from the pressure on the esophagus and
pharynx
→ Check if it does not interfere with a vital
function such as respiration or causing
discomfort
→ Observe closely the first time the child
drinks after the procedure to ensure that
the gag reflex is intact despite throat
edema or the effect of a local pharyngeal
anesthetic that may have been sprayed
into the throat before the procedure.
BRONCHOSCOPY
• Bronchoscopy is the direct visualization of
the larynx, trachea, and bronchi through a
lit, flexible, fiberoptic tube (i.e., a
bronchofiberscope) that is passed through
the naris or trachea.
• The procedure is used with children who
have aspirated a foreign object, to instill
certain medications, or to take culture and
or biopsy specimens
• Typically, the throat is sprayed with a local
pharyngeal anesthetic to numb the area.
• Because the procedure can be frightening
and this makes it difficult for a child to
cooperate a sedative or conscious sedation
usually is administered
• Any manipulation of the airway has the
potential to cause increased bronchial
secretions and edema which might lead to
narrowing of the airway
Aftercare:
→ Closely observe the child’s respiratory
function and airway for at least 4 hours
after the procedure
→ Apply an ice bag applied to the neck
→ Assess for the presence of a gag reflex
before offering any oral fluids to the child
after the procedure
→ Observe children carefully the first time
they drink after the procedure to assess
that their gag reflex is intact and they do
not choke.
COLONOSCOPY
• Colonoscopy is an endoscopic examination
of the large intestine with a flexible
fiberscope that is inserted through the anus
and advanced as far as the ileocecal
valve.
• Air is then infused to expand the bowel
walls for good visualization.
• The technique allows the colon walls to be
visualized; if abnormalities are found,
photographs can be taken for analysis.
• It is used to diagnose inflammatory bowel
disease or to obtain biopsies if a
malignancy is suspected.
• Before the procedure, children are given a
clear liquid diet for about 24 hours and
then they are asked to drink an isotonic
saline laxative that causes fluid diarrhea so
their bowel is clean for the procedure. It
can be difficult for younger children to
drink as much of the laxative solution as is
needed so their bowel is cleared
completely of stool
• Playing games such as Simon Says can be
helpful to gain their cooperation. If a child
cannot swallow all the laxative, a saline
enema may be necessary. Moderate
sedation is used during the procedure to
reduce discomfort.
Aftercare
→ Discharged about 2 hours after the
procedure (keep on NPO)
→ May pass flatus in the first 12 hours
→ Instruct parents to observe the ff:
abdominal pain, blood in stool, weakness,
or paleness (signs of bowel bleeding)
→ Give generous praise afterward
ASPIRATION STUDIES: LUMBAR PUNCTURE
• Removal of body fluids
by such techniques as
lumbar puncture or bone
marrow aspiration
• Anxiety-causing procedures
• Frightening. A child may need a sedative
or conscious sedation
• Have child lie quietly
Aftercare:
→ Assess how well a child reacted to the
procedure by both observation and history
→ Explain what happened. It helps them
retrace the procedure
→ Fill in gaps in information
→ Providing therapeutic play
36
SPECIMEN COLLECTION
• The collection of body fluids, secretions,
and excretions
• A collaborative nursing function essential to
the complete assessment of a child
• Elements of these fluids are measured by a
variety of means; findings can be used to
help diagnose an illness, evaluate the
progress of a condition, or evaluate a
child’s response to therapy.
• As with all procedures, use standard
infection precautions regardless of the
source from which the sample is taken.
OBTAINING BLOOD SPECIMEN
• Having a blood specimen taken can be
terrifying for a child.
• For many children, their past experience
with losing blood has involved a nosebleed
or a cut knee and the discomfort or pain
they felt. They have also had injections for
immunizations, so they know that injections
sting.
• Putting the two experiences together
makes collecting a blood specimen an
extremely terrifying process.
• For these reasons, prepare children both
before and during the procedure.
CAPILLARY PUNCTURE
1. Capillary blood heel or fingertip punctures
– for glucose and hematocrit
determinations
→ For heel punctures, use the lateral aspect
of the heel to avoid striking the medial
plantar artery or the periosteum of the
bone
2. Use the side of the finger, not the center
3. Apply EMLA Cream before the procedure
→ Comfort the child afterward as puncture
techniques can be as painful as
venipuncture
OBTAINING URINE SPECIMENS
• Depending on the type of test required,
urine may be collected with a usual
voiding, after the external meatus has
been cleaned (i.e., a clean-catch specimen),
by catheterization, or suprapubic
aspiration.
• A specimen may require a single specimen
or collection of all the urine voided within a
24-hour period.
ROUTINE URINALYSIS
• Routine urinalysis requires only a single
voided specimen
• The specimen will then be analyzed for
appearance, glucose, specific gravity, and
microscopic analysis
• Specimens must always be collected in
sterile containers to prevent contamination
The Infant and Toddler
• An infant or a child who has not been toilet
trained cannot be expected to urinate on
command; thus, a collecting device must be
attached to the genitalia to collect their
next voiding.
• If an infant attempts to loosen the collector,
cover the device with a diaper to keep it
out of reach. Otherwise, leave the device
visible so that it can be observed for urine
output.
• Offer the child something to drink to
encourage voiding.
• Most infants void shortly after a feeding,
so if the collector is applied just before a
regular feeding, voiding will probably
result soon afterward.
• Remove the collector as soon as the infant
voids and transfer the specimen to a
specimen cup by cutting a bottom corner of
the bag.
The Preschooler and School-Age Child
• It may be difficult to obtain routine urine
specimens from preschoolers or toilet-
trained toddlers because they can void
only when they feel a definite urge to do
so, not on command. Another problem is
language. It is not unprofessional to use
words such as “pee-pee” if this is what the
child will understand.
• Provide a potty chair if one is available; if
not, put a urine collection cap device on a
toilet.
• A generally successful approach with a
child this age is to act as if voiding is not a
difficult procedure.
• Offer the child a glass of water or other
fluid and ask a parent to reinforce the
request to void so that the child knows a
parent approves.
37
• A school-age child is usually able to void
when asked, although the child may find it
more difficult than the adult.
The Adolescent
• Adolescents are usually knowledgeable
and cooperative about providing urine
specimens.
• As with adults, give them a clean specimen
container and tell them what is needed.
Unless they have voided recently, they
usually are able to void on command.
• Remember, however, that adolescents are
concerned and self-conscious about body
functions and therefore are often reluctant
to carry a urine specimen through a
crowded waiting room to the desk area.
• They may be too self-conscious to void if
they know someone is nearby, for
example, just outside a curtain waiting for
them.
• Send them to a nearby bathroom with a
closed door, or leave the area to give
them privacy.
• Adolescent girls may be embarrassed to
mention they are menstruating so be sure
to ask an adolescent girl about this before
she voids.
• To prevent having a urine specimen
contaminated by menstrual blood, which
changes the specific gravity, protein, and
red blood cell analysis, ask the girl who is
menstruating to wash her perineum well
with soap and water and rinse and dry it
to remove menstrual blood.
Twenty-Four–Hour Urine Specimens
• Although a urinalysis of a single urine
specimen will indicate the presence of
substances such as protein or glucose, a 24-
hour urine specimen may be necessary to
determine how much of a substance is
excreted during a full day (quantitative
analysis).
• To begin a 24-hour urine collection, ask a
child to void (with an infant, attach a
collecting bag and wait for the child to
void).
• This specimen (i.e., the discard specimen) is
discarded so that a specific time for the
ensuing collection is known.
• If the urine collection was started early in
the morning and this first specimen was
counted as part of the collection, the urine
collected during the next 24 hours would
include urine that had been forming all
night, resulting in an approximately 32-
hour collection period that would distort the
analysis.
• Record the time of the collection as being
from the time of the discarded urine to the
final specimen added to the collection.
• For an infant, use a 24-hour rather than a
single specimen urine collector. These types
of collectors, however, will adhere for this
length of time only if a child’s perineum is
thoroughly dry at the time of application.
• Also, before applying the collector, apply
tincture of benzoin or a commercial product
to make the skin somewhat tacky and to
help the collector firmly adhere to the skin.
• After the collector is applied, place the
infant in a semi-Fowler’s position, if
possible, to encourage urine to flow freely
into the collector. It may be necessary to
place a diaper on the infant to keep the
apparatus out of sight. Make certain the
tubing from the collector is pinned out of
the infant’s reach or the infant may pull the
collector free. Provide activities for the
child and make sure the parents
understand they can pick up infants and
hold them during this time as long as they
take care not to kink or pull the tubing
• To keep the bacterial count to a minimum,
24-hour collection containers are generally
kept on ice; after each voiding, pour the
new specimen into the larger container,
which is kept refrigerated for the 24-hour
period and until it can be transported to
the laboratory for analysis.
Catheterization
• (#5 or #8) feeding tube is used instead of
a urinary catheter
→ because such a thin tube passes readily
through the meatus of even an infant.
• U.M. is not as readily observable infants
and young children as it is in women
• Cleanse the perineum or penis well before
inserting the tube
• An invasive procedure, so children must be
prepared in advance
→ caution children that the catheter will
sting for an instant as it is inserted and
they will have to lie still until the urine
specimen is obtained
38
 → They need both support to submit to the
procedure and give praise afterward for
their cooperation
→ Preschool boys may need assurance that
the procedure has no long-term
consequences to reduce their fear of
castration
SUPRAPUBIC ASPIRATION
• the withdrawal of urine by insertion of a
sterile needle into the bladder through the
anterior wall of the abdomen
• used to obtain urine for culture in infants
who cannot void on command
• done by physicians, although nurse
practitioners or nurses in specialty units
may perform it
Steps:
1. The anterior abdominal wall is cleaned
with an antiseptic, the urinary meatus is
blocked by gloved finger pressure,
confining urine in the bladder
2. A needle is inserted just above the
pubis into the bladder and the urine is
aspirated through the needle into a
sterile syringe. Although suprapubic
aspiration for urine appears
complicated actually it is not, the
bladder is the most interior of
abdominal organs and when the
standard with urine is easily accessible
just under the abdominal wall. Because
the needle can cause a bladder spasm
however it can produce sharp
discomfort. Parents may not have
heard of this procedure and may
wonder why their child had urine
drawn by needle and syringe instead
of by catheter. The method is used
because theoretically the risk of
bladder infection from needle insertion
is less than that from predator insertion
STOOL SPECIMEN
• To be analyzed for blood or ova and
parasites
• For toilet-trained – use a potty seat or by
placing a collector cap device on a toilet
• Know the word the child uses for stool
• Transfer the specimen to a collection cup
with tongue blades
• For not toilet-trained – scrape stool from a
diaper using tongue blades and place it in
a stool collection cup
• Some specimens need a preservative
• Send to the laboratory promptly (less than
an hour)
• Specimens should be sent to the laboratory
promptly so they do not dry and have to
be collected a second time because most
children need at least 24 more hours to
produce a stool specimen. If the stool
specimen is for ova and parasites, do not
refrigerate it because refrigeration
destroys the organisms to be analyzed.
ENTERAL FEEDINGS
• Enteral feedings, also called nasogastric or
orogastric tube feedings, are a common
means of supplying adequate nutrition to
an infant who is unable to suck (or who tires
too easily when sucking) or to an older
child who cannot chew or swallow.
• Enteral feedings have the advantage over
parenteral (i.e., intravenous) nutrition
because they preserve the stomach mucosa
and also decrease the risk of intravenous
infiltration or infection.
• In infants, such feedings may be referred
to as gavage feedings
• Newborns are nose breathers, pass a
catheter through the mouth
→ Because newborns are obligate nasal
breathers, passing a catheter through
the nose may obstruct their breathing
space, and repeated insertion of a
nasal gastric tube can cause
inflammation and obstruction of the
nose; thus, most tubes are inserted
orally in small infants
• Orogastric insertion can also decrease the
possibility of striking the vagal nerve in the
back of the throat and causing
bradycardia.
• For older children, insertion through a
nostril is often more comfortable.
• To prevent irritation or ulcer formation
from the tube rubbing against the tip of the
nose, always tape nasogastric tubes to the
child’s cheek rather than the forehead to
secure it in place.
• At the end of the feeding, flush the tube
with 1 to 5 ml of water to clear it of the
feeding solution, prevent blockage, and
maintain patency. Keep the child’s head
elevated for at least 1 hour after a
feeding to help prevent esophageal reflux.
Provide mouth care at least twice a day to
encourage salivation in children who are
39
 receiving nasogastric tube feedings;
otherwise, their mouths can become dry
and prone to the formation of mucosal
ulcers.
GASTROSTOMY TUBE FEEDINGS
• Indication: cannot swallow or those with
esophageal atresia, severe
gastroesophageal reflux, or esophageal
stricture
→ is one inserted under regional anesthesia
through an abdominal puncture site into
the stomach and used for nutritional
formula feedings
• An indwelling urinary catheter (Foley
Catheter) rather than a true gastronomy
tube is used
→ because these are smaller in size, can be
removed easily, and changed should they
become plugged. In addition, the balloon
used to secure the tube is small enough so
it does not obscure and fill the small
stomach space
• Should be at room temperature
• Elevate the child’s upper trunk 30-40
degrees
• Hold an infant in the lap or placing him or
her in an infant seat
• For an older child, use pillows or elevate
the head of the bed
• After the feeding, flush the tube with a
specified amount of clear water
• Keep the child’s head elevated for at least
1 hour after feeding
• If had esophageal surgery, suspend the
unclamped tube in an elevated position.
Leaving the tube unclamped and elevated
ensures that if the child should vomit,
vomitus will be evacuated from the stomach
by the tube rather than past new sutures in
the esophagus
• If a tube is left elevated and unclogged
cover it with a clean piece of porous gauze
to prevent bacteria from entering it
• Infants who are fed by gastrostomy tube
miss the pleasure of sucking you may offer
a pacifier to suck on during the procedure
unless it is contraindicated and you may
talk or saying to the child as if the feeding
were being given orally
Major Complications
• Obstruction - The biggest problem with
managing gastrostomy tubes is they may
not fit snugly, so formula or irritating
gastric secretions can leak around the tube
onto the abdominal skin.
• Observe and report any vomiting,
abdominal distention, or brown or green
tube drainage (duodenal secretions)
• Clean the skin around the nipple daily
wherein you can use this as one technique
with a product such as your half hydrogen
peroxide
• Change the skin protectant as directed by
the manufacturer's instructions at the time
of the change expose the skin to air for
approximately one hour to keep the skin
dry
• Test for residual aspiration fluid
→ Stomach secretions – acid
→ Duodenal secretions – alkaline
TOTAL PARENTERAL NUTRITION
• Total parenteral nutrition (TPN), or nutrition
administered intravenously, has become
one of the most important therapies for
children who have gastrointestinal illnesses
that prevent proper absorption of basic
caloric or fluid requirements or respiratory
illnesses that make infants too exhausted to
suck.
• Traditional intravenous therapy contains
fluid, electrolytes, and sugars but not
protein and fat, ingredients which are
essential for the maintenance and growth
of body tissues.
• With TPN, all of a child’s nutritional needs
can be met by a concentrated hypertonic
solution containing glucose, vitamins,
electrolytes, trace minerals, and protein.
• An intralipid solution (emulsified fat able to
be administered intravenously), given once
or twice per week, supplies needed fatty
acids.
• Children with chronic diarrhea or vomiting,
inflammatory bowel disease, bowel
obstruction, anorexia, or extreme
immaturity are examples of children who
benefit greatly from TPN
• TPN solutions may be administered via a
central intravenous access site or via a
peripherally inserted central venous
catheter (PICC line)
• If a central access site is chosen, a catheter
is inserted through the right external
jugular vein into the superior vena cava, or
directly into the subclavian vein under strict
aseptic conditions
40
• The catheter is secured at the site of
insertion with sutures and covered with a
sterile dressing to help reduce bacterial
invasion.
• A major vein of this type is chosen to avoid
inflammation reactions and resulting venous
thrombosis from the high-caloric and high-
osmotic fluid that will be infused.
ASSISTANCE WITH ELIMINATION
• Special care for Intestinal Elimination
1. Administration of Enemas
2. Ostomy care
ADMINISTRATION OF ENEMAS
• An enema involves inserting liquid or gas
into the rectum, which is the lower part of
the large intestine. The aim to empty the
bowels, allow for an examination or
administration medication
• Enemas are rarely used with children unless
they are used as therapy for fecal
impaction, Hirschsprung disease, a part of
preparation for surgery, or a diagnostic
test. If an enema is necessary, offer a
careful explanation of what the child can
expect.
• The aim of this procedure is to empty the
bowels allow for an examination or
administer certain medications
• As the sizes of children’s bowels vary
greatly, the usual amounts of enema
solutions used are:
→ Infant: less than 250 ml (exact amount
should be stipulated by primary care
provider’s prescription)
→ Preschooler: 250 to 350 ml
→ School-age child: 300 to 500 ml
→ Adolescent: 500 ml
• For an infant, use a small, soft catheter
(#10 to #12 French) in place of an enema
tip to prevent rectal trauma.
• Lubricate the catheter generously with a
water-soluble lubricant and insert it only 2
to 3 in. (5 to 7 cm) in children and only 1
in. (2.5 cm) in infants.
• If using an enema bag, hold the solution
container no more than 1 ft above the level
of the sigmoid colon (12 to 15 in. above
the bed surface) so the solution flows at a
controlled rate.
• If a child experiences intestinal cramping,
clamp the tubing to halt the flow
temporarily and wait until the cramping
passes before instilling any more fluid.
• An older child can be instructed to take
deep breaths to reduce
guarding of abdominal
muscles and to help the
cramping sensation pass.
• Infants and children up to
ages 3 or 4 years cannot
retain enema solutions at
all, so hold the buttocks together for a short
time to prevent immediate expulsion of the
solution, or pad the edge of a bedpan so it
is not cold or sharp, and rest their pelvis on
it following the procedure.
• Commercial enemas, such as Fleet enemas,
are not routinely administered to children
younger than 2 years of age because of
the harsh action of the sodium biphosphate
and sodium phosphate they contain.
• Tap water is not used either because, as it
is not isotonic, it causes a rapid shift of fluid
in body compartments, possibly leading to
water intoxication.
• Although a solution of milk and molasses
may be used in an emergency department
to relieve a fecal impaction, normal saline
(0.9% sodium chloride) is the usual solution
used. It can be made by parents at home
by adding 1 teaspoonful of salt to 1 pint
(500 ml) of water
PROVIDING OSTOMY CARE
• An ostomy is a surgically formed opening
from an internal structure to the surface of
the body.
• Ostomies in newborns are created in the
gastrointestinal system to relieve bowel
obstruction caused by conditions such as
ileal atresia, necrotizing enterocolitis, and
imperforate anus.
• In older children, gastrointestinal ostomies
are constructed for conditions such as
inflammatory bowel disease, Crohn
disease, and ulcerative colitis
• Indications of children having ostomy
→ Necrotizing Enterocolitis: where there is
the affected intestine compared to the
healthy intestine
41
 → Imperforate anus: check the body
temperature of an infant by a rectum
• If an ostomy is created in the ilium
→ it is called an ileostomy the stoma is
located on the right side of the abdomen
and drains liquid stool which is extremely
irritating to the skin because of the
digestive enzymes it contains
• If an ostomy is created in the sigmoid
portion of the bowel
→ this is what we term as your colostomy, the
stomach on the opening is on the left
lower abdomen and passes normally form
stool compared to Ileostomy
• An ileostomy requires the use of a
collecting ostomy appliance to contain acid
stool and to prevent excoriation of the
abdominal skin.
• Two basic problems commonly arise when
using an ostomy appliance with an infant: It
may be difficult to locate one small enough
to contain liquid drainage without leaking,
and the skin under the appliance may
become extremely irritated.
• Consulting with a wound ostomy continence
nurse (WOCN) can be helpful to resolve
these problems.
• As a rule, clear plastic, ringless colostomy
bags are more easily cut to fit the size of
the stoma and the contour and size of an
infant’s abdomen than bags with a ring
attached.
• When using a commercial skin sealant to
harden the skin surrounding the stoma,
apply it according to the brand directions
and allow it to dry.
• If a spray is used, protect the infant’s face
so that the infant does not inhale the
solution.
• Tuck the chosen stoma collection appliance
inside the diaper to help keep the infant
from pulling it loose.
• Wash and dry the stoma and surrounding
skin area well
• Follow your agency’s protocol for skin care,
such as applying karaya powder, an
ointment such as Desitin, or
• Skin protectant to protect the skin
• Check the appliance or bag for collecting
stool at least every 4 hours. To protect the
underlying skin, do not remove a self-
adhering bag if it is full but drain collected
stool from the bottom of the appliance into
a basin or paper cup for disposal.
• To reduce odor, flush the appliance bag
with a warm water and soap solution, using
a bulb-type syringe (an Asepto syringe),
and rinse with clear water.
• The collection bag may stay in place for as
long as 1 week if properly secured.
• To remove a bag that was placed with a
sealant, use the designated solvent to
prevent pulling or harming the underlying
skin.
• After removal, wash the skin with soap and
water or the solvent can become an irritant.
• Because most infants enjoy tub bathing, a
long, soaking bath is an excellent way to
loosen an adherent appliance.
• Reassure parents caring for an infant with
an ostomy that little is different from usual
because all parents must change their
infant’s diapers frequently and clean the
diapered area. Discuss with parents that
the stoma has no nerves, so a parent can
feel free to wash it without hurting the child
and that compression against the stoma will
not cause a child pain so the parent can
feel comfortable placing an infant on the
abdomen or holding the infant closely
against his or her body for comfort.
PREPARING OF A CHILD FOR SURGERY
• Preparing a child for surgery is a major
responsibility for a child health nurse
• Such preparation differs according to the
type of surgery being performed but
certain activities apply to all surgery and
all children
• Psychological preparation of both child
and parents is aimed at reducing a child’s
fears about the procedure and consists
primarily of providing health teaching and
opportunities for therapeutic play
• Physical preparation includes:
1. Restrictions on food and fluid intake
before surgery,
2. Preparing the incision site on the child’s
skin, and,
3. Arrange for transportation of the child to
surgery
42
 → Because many children surgical
procedures are done on an ambulatory
basis preparation must also include
informing parents about the details of the
preparation techniques the surgery the
post-operative period and the steps they
must take toward the preparations is
PREPARE A CHILD EMOTIONALLY
→ Prior the surgical intervention this requires
1. minimizing fears common to all children
like (fear of separation, fear of
mutilation, or fear of death)
2. Tell a child about the procedure and
describing any specific equipment and
techniques that will be used such as
anesthesia, the use of eye bandages,
nasogastric tubes, sutures or special
after care
3. A teaching plan is also essential for
explaining all of these features of
surgery to the child
→ Be certain or preparation is appropriate
to the child's age more children
undergoing surgery receive a general
anesthetic rather than a local original
anesthetic as might be used with adults
because this minimizes their fears of
intrusive or mutilating procedures and
because children who are not yet
adolescent are not mature enough to
cooperate adequately during surgery
PHYSICAL PREPARATION
1. Placed on nothing by mouth (NPO)
status for surgery
2. Preparation of surgical sites varies
3. Give a great deal of assurance that
the solution being used will not sting
but is only cleaning
→ Surgery the length of the time the child
will remain NPO depends on the child's
age adolescents and school-aged children
may be restricted from taking food or
fluid from midnight until the time of
surgery the following morning
→ However, if infants younger than six
months were held in po for as long a time
as this they would be taken to surgery in
dehydration therefore infants younger
than six months may be kept NPO for as
little as four hours
→ At the end of the four hours as the infant
becomes hungry he or she will begin to
cry and fuss
→ Parents need an explanation that infants
will vomit during surgery
→ Because of recent readings may aspirate
therefore even though an infant is
becoming hungry he or she must be
restricted from ingesting
→ Although a hungry child will usually not
suck when a pacifier can be offered
POSTOPERATIVE WOUND CARE
• Children frequently have a dressing or
bandage put in place to cover a surgical
incision or sutured laceration. Such
dressings are the same as those used with
adults except in size, material, and
methods used to secure them.
• Keeping a dressing dry to avoid
introducing infection to the wound in infants
and toddlers who are not toilet trained can
be a major problem if the dressing is near
the diaper area.
• In many instances after surgery, collodion
(i.e., a clear substance similar to nail polish)
or other commercially available “wound
glues” are used to cover the incision
because these solutions not only replace
stitches but also keep the incision line from
coming in contact with urine or feces.
• These materials allow good visualization of
the healing surface as well because they
are clear.
• Assure parents that such a covering is
adequate and actually preferable if the
incision is in the groin such as from a hernia
repair. They are also preferable if an
incision or laceration is on the face because
they tend to heal with less scarring than if
sutures were used
• If a gauze dressing is used near the diaper
area, it can be covered with plastic and
held in place with nonadhesive, waterproof
tape to protect it from becoming soiled.
When cutting plastic to cover a dressing,
do not to leave an extra piece behind in
the crib because a child could pull this over
the head and suffocate.
• Occlusive dressings (e.g., hydrogel sheets,
hydrocolloids, polyurethane films) are
dressings especially designed to keep a
healing surface clean and dry.
• Apply and remove these according to each
product’s directions or agency policy to
protect irritating the skin underneath.
43
TRANSPORTATION
transporting a child to the operating room
needs also ample preparations
1. Check children’s identification bands
2. Remove barrettes and bobby pins from the
child’s hair and check the mouth for loose
teeth
→ Particularly for ages 6, 7, and 8 years
who are losing their central and lateral
incisors or for dental appliances it is
rare to find a child with full dentures but
not uncommon to find a post or screw in
tooth that may have to be removed
before surgery or a retainer used to
maintain orthodontic collection after
brace removal
→ Teeth braces do not need to be
removed make certain the
anesthesiologist knows about any loose
teeth before an airway for surgery is
inserted
→ A loose teeth could be knocked totally
free and aspirated during the
procedure
3. Changing to a hospital gown is a terrifying
moment
→ For some children having to give up
their own pajamas or their bedroom
sleepers or outside shoes to change the
hospital gown is a terrifying moment
→ Giving up underpants is a step that
many preschool and early school-aged
children cannot tolerate for this reason
many children are allowed to wear their
own pajamas or clothes until they are
under an anesthetic
4. A child may walk to surgery
→ In ambulatory settings children may
walk to the surgery area if they will
ride in a car this should have been
introduced during the preparation be
sure to fasten a restraining strap for
safety preschoolers may enjoy taking a
favorite toy or blanket to surgery with
them ideally they should be allowed to
keep this with them until they are under
an anesthetic
→ Parents should be allowed to
accompany their children to the
operating room
→ Some parents can accompany their child
into an anesthesiologist induction room
for others this is an appropriate or to
anxiety producing
5. A nurse whom the child knows should
accompany the child to the operating room
→ Even if the child has been well-treated
for the surgical experience under the
anesthetic and the change in personnel
and arrival to the surgical suite saying
goodbye to parents at the door of the
surgical suite and the actual site of
strange personnel can lead to high
levels of anxiety and fear
44

NURSING CARE OF A FAMILY WHEN A
CHILD NEEDS MEDICATION
ADMINISTRATION OR INTRAVENOUS
THERAPY
ROUTE OF ADMINISTRATION
ORAL
• Children younger than 3 years of age are
unable to swallow pills. However, the
ability of children to swallow pills varies
from one child to the next and is not age-
dependent. Typically, children older than 9
years of age can be offered tablets;
however, some adolescents are not
capable of swallowing tablets. The best
practice is to ask the child and parent
whether they are able to swallow tablets
before offering the tablet form of the
medication. Most oral medications for
young children are available in liquid,
chewable, or meltaway forms
• In infants, oral medication can be given
with a medicine dropper or a unit-dose
oral syringe (without a needle). Never give
medicine with the child lying completely
flat; otherwise, a child could choke and
aspirate. Instead, gently restrain the child’s
arms and head by holding the child against
your body with the head raised
• Preschoolers and early school-age children
respond well to rewards such as stickers or
small prizes each time they take their
medicine. For older children, hand them the
cup of liquid or tablet medicine and offer
them a favorite fluid to swallow
• If a child has difficulty swallowing tablets,
some pills can be crushed or added to a
teaspoonful of applesauce or a flavored
syrup. If pills are not to be chewed (e.g.,
capsules, enteric coated tablets), be certain
to tell the child not to chew them.
OTIC
• Otic administration refers to administering
medicine, primarily drops, into the ear
canal.
• Like other forms of medicine, this is difficult
for children to accept because they have
been told many times not to put anything
into their ears.
• Also, because ear drops are generally
administered for an earache, which is
sharp, excruciating pain, a child may worry
having medicine put into the ear will make
the pain even worse.
• In addition, a child’s inability to watch what
is happening may contribute to the child’s
fear. It is important to be honest with the
child and provide information that is
developmentally appropriate.
• Ear drops must always be used at room
temperature or warmed slightly because
cold fluid may exacerbate pain and may
also cause severe vertigo as it touches the
tympanic membrane
• If the child is younger than 2 years of age,
straighten the external ear canal by pulling
the pinna down and back. If the child is
older than 2 years of age, pull the pinna
of the ear up and back. Instill the specified
number of drops into the ear canal. Hold
the child’s head in the sideways position to
ensure the medication fills the entire ear
canal.
OPTHALMIC
• Eye medications, in particular, antibiotics to
treat eye infections, are administered by
being dropped into the conjunctival sac of
the eye
• This type of administration, like nose drops,
is frightening for children because the eyes
are a sensitive area and a natural reflex
occurs to avoid contact with the eyes.
• As a result, infants and preschoolers
generally may need to be restrained for
eye drop administration.
• Always prepare the child first, with a
developmentally appropriate explanation.
Place the child on his or her back.
• Open the eyes of infants and preschoolers
by gently but firmly pressing on the lower
lid with the thumb and on the upper lid with
the index finger.
• A school-age child or adolescent will open
their eyes cooperatively, but you may
need to rest a hand on the eyelid to keep
the eye open long enough for the drug to
be administered.
• To instill an ophthalmic ointment, apply a
fine line of the ointment along the inside
rim of the conjunctival sac, working from
the inner to the outer eye canthus; be
careful not to touch the tube to the eye.
INTRANASAL
• Drugs are well absorbed across the nasal
mucosa, so this route is an effective means
of drug administration and can be a route
45
 for important and even life-sustaining
drugs.
• Turn the child or ask the child to turn onto
his or her back. A school-age child can
extend the head over the side of the bed
so that it is lower than the trunk.
• Preschoolers generally are too frightened
by this strange position and do better with
a pillow under their shoulders so that their
head extends over the pillow and rests
downward.
• Infant may need to be restrained in a
mummy restraint for nose drop
administration if they struggle to keep the
syringe or dropper away from their nose
• Instill the appropriate number of drops into
one nostril. Turn the child’s head to the
side—to the left after the left nostril, to the
right after the right nostril—so that the
medicine stays in the nose longer.
• If the child is a preschooler or older, ask
him or her to further “sniff” the medicine so
that it goes far back into their nose. If a
child gets up immediately, the medicine will
flow out and will be less effective.
• Therefore, have the child remain in the
head-flat position for at least 1 minute to
be certain the medicine remains in contact
with the mucous membrane of the nose.
INTRAVENOUS
• Medications may be added to an IV line as
a small, one-time administration (bolus), a
fluid chamber infusion, or by piggyback
for larger children.
• As with any medication administration,
identify the child before adding medicine
• to an IV line. Also ensure that the drug to
be injected is compatible with the IV fluid
being infused.
• To administer medicine using a bolus
technique, depending on what is available
and the protocol at your facility, you may
use a syringe pump for administering a
medication or, if giving an IV push
medication, clamp the IV tubing above the
medicine port in the IV line, clean the port
with alcohol, insert the needleless syringe
filled with the prescribed medicine into the
port, and inject the medicine slowly and
gently based on the manufacturer’s
instructions.
• Once the medication has been given,
remove the syringe and reopen the IV line
immediately to allow the IV solution to flush
the medicine into the child.
• For a piggyback infusion of medicine,
medication is provided by the pharmacy
prepared and diluted in small fluid-filled
plastic bags. To begin a piggyback
infusion, hang the piggyback bag, clean
the medicine port on the IV line, and insert
the piggyback system into the port. Lower
the level of the main infusion bag and
adjust the flow rate to that desired to
allow the piggyback system to operate. As
soon as the piggyback bag has emptied,
elevate the maintenance bag of fluid
again and make certain the IV line is
flowing well and at the proper rate.
RECTAL
• recommended. Rectal administration not
only assist in absorption across the mucous
membrane of the intestine but also avoids
the danger of aspiration in certain
situations such as seizures or when a patient
is unconscious
• This method may be difficult for children
due to its invasive nature; therefore, it is
not a major route of administration.
• Also given by this route are rectal
suppositories and retention enemas.
• Many suppositories are supplied already
lubricated. If not, add a drop of water-
based lubricant such as K-Y Jelly to the tip.
• Use a glove and insert the suppository
gently but quickly beyond the rectal
sphincters (approximately 0.5 in.)
TRANSDERMAL/TROPICAL
• Children sometimes require administration
of topical creams or lotions for skin
irritation or to relieve itching or dryness.
Most children are more tolerant of this type
of application because it may provide
immediate relief of symptoms.
• Older children may be able to assist with
topical applications with your supervision.
Be certain they wash their hands afterward
so they do not lick any extra off their
fingers and inadvertently take it orally
• Transdermal patches are an effective and
pain-free route of administration of
medication absorbed through the skin. The
child’s skin should be dry and intact at the
site where the patch will be applied. Apply
a patch over the trunk or a major muscle,
not on distal extremities, for best
absorption.
46
• If possible, change the site every time a
new patch is applied to decrease the
possibility of irritation to the skin from the
patch and clean the area of the skin
before application
• Young children tend to remove transdermal
patches the same as they do Band-Aids
because of normal curiosity about what is
underneath
INTRAMUSCULAR AND SUBCUTANEOUS
• IM injections are rarely prescribed for
children admitted to the hospital because
many children do not have sufficient muscle
mass for easy deposition of medication
and they are also painful. However, IM
injections may be used in an emergency
department and are commonly used for
immunization. For IM injections in infants,
the preferred site for administration is the
vastus lateralis muscle of the anterior thigh
• Use the lateral aspect rather than the
medial portion because this site is not as
tender and should cause less pain. Using
the gluteal muscle in children younger than
1 year of age is to be avoided due to the
risk of damage to the sciatic nerve
• In older children, as in adults, the deltoid
muscle or a ventrogluteal site should be
used.
SUBCUTANEOUS PUMP INFUSION
• Continuous subcutaneous pump infusion
using a medication pump is the
administration of a medication by the
constant infusion into the subcutaneous
tissue
• With a subcutaneous infusion pump, the
drug is delivered by the pump via a
medicine-filled syringe.
• The site chosen is usually the abdomen
because this both protects the pump and
allows it to be out of sight.
• The hub of the medicine-filled syringe is
attached to a small tube with the needle
attached at the distal end.
• The syringe is then clamped to the pump,
the skin site is cleaned with alcohol, and the
needle is inserted at a 45-degree angle
(the usual subcutaneous insertion technique).
• The needle is typically retracted, leaving a
small catheter in the subcutaneous tissue,
which is taped in place before the pump is
turned
• The insertion site should be changed every
3 days to reduce the possibility of
infection. The pump should be removed
before showering so it doesn’t get wet,
although the catheter can remain in the
subcutaneous tissue.
AUTOINJECTION SYRINGE
• Some medicines, such as insulin, come
prepared in autoinject syringes that
children are able to use to self-inject as
soon as they are about 5 or 6 years old.
• Such injectable syringes have advantages
in that they are prefilled with the correct
amount of medicine, the needle is small,
and the spring that causes the needle to
inject the medication acts quickly, reducing
pain during injection.
• You may need to remind preschool children
not to play with the syringe or school-age
children not to use it as a weapon against
their friends or they could unintentionally
inject them with the medicine.
MEDICATION ADMINISTRATION AND
CHILDREN
• Young children do not understand that
taking the medicine you offer them will be
important to relieve whatever symptoms
they are experiencing from an illness
• The child’s chronologic and cognitive level
will aid in planning the level of explanation
that will be needed
• The child’s developmental age reveals if a
child can swallow oral medicine or will be
able to use such self-medication methods; it
will help you determine which site would be
best for an IM or IV injection
• Children vary so greatly in size and
individual need that weight-based dosing
is required. For some medications, such as
chemotherapy, body surface area dosing is
required
NURSING PROCESS
ASSESSMENT
NURSING DIAGNOSIS
• Disturbed sleep patterns related to q4h
(every 4 hours) timing of medication
administration
• Deficient knowledge related to action and
side effects of the medication
• Fear related to IV administration of
medicine
• Discomfort related to side effect of
medicine
47
• Health-seeking behaviors by parent
related to desire to learn more about
different type of medicine available for
child’s illness
OUTCOME
IMPLEMENTATION
PHARMACOKINETICS IN CHILDREN
ABSORPTION
• Drug absorption (the transfer of the drug
from its point of entry in the body into the
bloodstream) is influenced by the route of
administration as well as by the
concentration and acidity of the drug
• Some routes of administration in children
are limited and so are rarely used. For
example, children younger than school age
usually cannot hold tablets under their
tongue for sublingual administration; they
tend to swallow them instead.
• The small muscle size of young children
limits sites for IM injection. Transdermal
patches can be easily removed by infants.
The gastrointestinal system may be so
immature at birth that gastrointestinal
absorption can be ineffective. Vomiting
and diarrhea, frequent symptoms of
childhood illnesses, also interfere with
absorption because a drug does not
remain in the gastrointestinal tract long
enough to be absorbed.
DISTRIBUTION
• Distribution refers to the movement of the
drug through the bloodstream to a specific
site of action. Children tend to have more
fluid held in interstitial spaces and less in
intracellular spaces than adults, so drugs
may not be distributed as quickly as in
adults.
METABOLISM
• Metabolism involves conversion of the drug
into an active form (biotransformation) or
into an inactive form (inactivation).
• Because a child’s basic metabolic rate is
faster than that of an adult, certain drugs
are metabolized more rapidly in children.
• This means that the drug must be
administered more frequently to a child to
maintain effective drug levels than it would
be in adults.
EXCRETION
• Excretion (the elimination of raw drug or
drug metabolites, a process that largely
prevents properly administered drugs from
becoming toxic) is potentially limited until
about 12 months of age, when kidney
function becomes mature.
• If a child has kidney disease, excretion
potential is limited at any age. A few
drugs, such as digitoxin, are excreted in
bile. Most newborns have sluggish bile
formation, so excretion of these drugs is
questionable.
• Monitoring intake and output is important
in children receiving drugs to be certain
urine excretion or an outlet for drug
metabolites is adequate.
ADMINISTRATION
ADVERSE DRUG EFFECTS
• Children respond to drugs in much the same
way as adults, but they may experience
unique or exaggerated side effects
because of immature liver function or rapid
metabolism during periods of rapid
growth. The newborn may suffer adverse
effects from drugs taken by the mother
prenatally or from drugs transferred in
breast milk.
SAFE STORAGE OF DRUGS
• Because young children do not appreciate
that overdoses of medicine can be serious
and even fatal, they may self-administer
additional doses of medicine resulting in
toxic levels of medications.
• This can occur with prescription medications,
over-the-counter medication, and even
alternative/complementary medications
• Adolescents can deliberately take extra
doses of drugs such as steroids or pain
medicine, hoping for an added effect.
Oxycodone (OxyContin), for example, is
an analgesic that may be prescribed for
adolescents and also is frequently abused
by them.
• Methylphenidate (Ritalin), administered to
children with attention deficit hyperactivity
disorder, is a second prescription drug that
may also be frequently abused
• Adults always need to be certain to store
medicine in a safe place.
• Because poisoning from medicine is a
frequent type of poisoning in preschool
children, children’s medicine—whether
prescription, over-the-counter, or
alternative/complimentary—should be
secured in a locked and safe place
48
RIGHTS OF MEDICATION ADMINISTRATION
RIGHT MEDICATION
• Most medication errors are made in
situations where multiple medications are
being administered in a fast-paced
environment
• Intensive care units and emergency
departments, therefore, are the highest
areas at risk for medication errors, often
because of interruptions during the
medication administration process
• Errors can occur because prescribers may
write a prescription using either generic or
trade names.
• It is the responsibility of the person
administering the medication to identify the
correct brand or generic equivalent.
RIGHT PATIENT
• When asked what is their name, children
cannot be depended on to reply with their
correct name.
• Anxious to please, a preschooler will
answer the question, “Are you Johnny
Jones?” with “yes.” He may also, however,
agree with any other name you propose.
• School-age children who want to avoid
taking a medicine may deny they are the
person whose name you called.
• To prevent these types of errors, never ask
children their names for identification.
Instead, read or scan the bar code on their
identification arm bands and compare
them with the medication sheet or electronic
record.
RIGHT DOSE
• The correct dosage of most drugs for
children is based on weight. However, for
drugs such as chemotherapy, the dosage is
based on a body surface, which requires
height and weight
• To calculate surface area using such a
chart, find the child’s height in the left
column (e.g., 40 cm); next, find the child’s
weight in the right column (e.g., 20 kg).
Hold a ruler or straightedge to connect the
two points. The mark at which the ruler
crosses the center column is the child’s body
surface area (e.g., 0.38 m2).
• Before administering any medication to a
child, confirm that the dose prescribed is
correct for the child’s weight or the child’s
body surface area.
RIGHT ROUTE AND TIME
• Each of these methods requires special
techniques because most children do not
enjoy taking medicine and need support
during administration.
• Proper spacing of time between doses is
also necessary for accurate medication
uptake, but choosing the right time of day
for parents to give medicine (e.g., planning
doses for 11 pm and 7 am instead of 8 pm
and 4 am) can positively impact the ability
of a family to successfully complete the
medication as prescribed.
RIGHT PATIENT’S INSTRUCTION &
DOCUMENTATION
• Because so many medications are
advertised on television or in magazines,
many parents and children are already
aware of drug names and the action of
individual drugs before they are
prescribed. However, because the
information provided may be limited, they
also may have misconceptions about a
particular drug. Be certain when giving
medicine to a child or handing a
prescription to a parent that you review
the drug’s purpose and action, when and
how it should be taken, and any side or
adverse effects the parent or child should
be aware of.
SAFE ADMINISTRATIONS
ORAL ROUTE
EAR AND EYE DROP
IM
INTRAVENOUS THERAPY
• In the past, IV therapy was used
extensively as a rapid means of hydrating
children who were dehydrated as a result
of diarrhea. Today, oral rehydration
therapy is most often used in this case
49
• IV therapy is a fast and effective means of
maintaining fluid and electrolyte balance,
producing therapeutic levels of drugs
quickly, to provide nutritional support and
offer blood or blood product replacement,
so it still has a common place in children’s
care.
• The amount, type, and rate of IV fluids for
children are prescribed carefully to
prevent fluid overload. IV fluid may be
infused into a peripheral vein, a central
venous access device, or a peripherally
inserted central venous catheter
DETERMINE FLUID AND CALORIE NEEDS
• IV fluid administered to children and
infants must be isotonic (exerts the same
osmotic pressure as their bloodstream) to
prevent the destruction of red blood cells
or the development of water intoxication.
• The use of isotonic fluid prevents fluid
shifting from the bloodstream into
interstitial tissue (as would happen if the IV
fluid were hypotonic) or fluid shifting from
interstitial tissue into the bloodstream (as
would happen if the IV fluid were
hypertonic).
• It is important to understand the principles
of IV therapy, including the fluid and
caloric needs of children (which differ
significantly from those of the adult), to
protect against overhydration,
underhydration, or electrolyte imbalances
such as hyponatremia
OBTAINING VENOUS ACCESS
• The needle size for IV therapy varies
depending on the solution and the rate at
which it will be administered. Commonly
used needle sizes include 22 gauge, 24
gauge, 25 gauge, or 27 gauge.
• Sites frequently used for IV insertion in
young children or infants include the veins
on the dorsal surface of the hand or on the
flexor surface of the wrist.
• Leg and foot veins also may be used.
• In infants, another site is a scalp vein over
the temporal area.
• Seeing IV fluid infusing into a scalp vein
can be frightening for parents because it
looks like a much more serious procedure
than an infusion administered into a hand.
• You can explain to parents that scalp vein
infusion is just another site to use to
administer fluid or medicine to infants and
ultimately might cause the least discomfort
for their child because needles there do not
infiltrate readily
DETERMINING THE RATE AND AMOUNT OF
FLUID ADMINISTRATION
• Because children’s hearts and circulatory
systems are smaller than those of adults, IV
fluid must be infused at a slower rate to
keep the child’s cardiovascular system from
becoming quickly overloaded.
• Therefore, just as in medication
administration, supervising the amount of
solution infused is critical. Infusion pumps
are required in most settings for infants
and children receiving IV fluids and when
giving potent medications and always for
small children because they regulate the
flow accurately to a few drops per minute
• Overloading of IV fluid in infants and
children can also be prevented by use of
fluid chambers, devices that allow only 50
to 100 ml of fluid into the drip chamber at
a time.
USING INTERMITTENT INFUSION DEVICES
INTERMITTENT INFUSION DEVICES
• Sometimes called saline locks, are devices
that maintain open venous access for
medicine administration while allowing
children to be free to move about without
being restricted by IV tubing and pumps
• A vein on the back of the hand is generally
chosen as the IV site.
• Connect intermittent infusion device to hub
of IV catheter
• Used to infuse multiple medicine when no
primary continuous fluids is needed
• Used to infuse multiple medicine when no
primary continuous fluids is needed
• The IV catheter is capped with needless
connection device or “heplock”
USING CENTRAL VENOUS ACCESS
CATHETERS AND DEVICES
• Venous access for long-term IV therapy can
be obtained using a tunneled catheter
inserted into the vena cava just outside the
right atrium; the catheter then exits the
chest just under the clavicle for easy access
• These catheters are usually inserted in the
operating room because tunneling under
the skin is required and general anesthesia
is preferred. These semipermanent
catheters are used to administer bolus or
50
 continuous infusions of medications and • Intraosseous infusion is painful as the
fluid needle enters the bone marrow cavity.
• Care of the catheter (depending on Prepare the child for this and offer support
agency policy) consists of dressing changes to both the child and caregiver.
over the exit site and periodically flushing VASCULAR ACCESS PORTS (VAPS)
the line with heparin or saline to ensure • Also known as Infusaports or PORT-A-
patency. CATHs, are small plastic infusion devices
• If this happens, it is an emergency situation that are implanted under the skin, usually
because the child could lose an on the anterior chest just under the clavicle,
appreciable amount of blood from the for long-term fluid or medication
point of entrance into the vena cava. administration via bolus or continuous
ADMINISTERING AN INTRAOSSEOUS administration
INFUSION
• Intraosseous infusion is the infusion of fluid
into the bone marrow cavity of a long
bone, usually the distal or proximal tibia,
the distal femur, or the iliac crest
• Because the bone marrow communicates
directly with the circulatory system, fluid
reaches the bloodstream as quickly by this
route as if it were administered
intravenously.
• All fluids that can be administered
intravenously, including whole blood or
medication, can also be administered by
this route.
• Intraosseous infusion is used in an
emergency when it is difficult to establish
usual IV access or in a child with such
extensive burns that the usual sites for IV
infusion are not available.
• It is a temporary measure until a usual
route of administration can be obtained
because of the danger of osteomyelitis, a
devastating infection with long-term effects
to bone marrow.

51
 PAIN MANAGEMENT IN CHILDREN
• Pain is a difficult concept to define because
it is a subjective symptom (experienced by
the person), not an objective one (able to
be determined using an objective scale),
and is unique to each person.
• Because it respects children’s opinion of
where and how much pain they feel,
McCaffery’s classic description of pain is
the one most useful to use with children:
• “The sensation of pain is whatever the
person experiencing it says it is, and it
exists whenever the person says it does.”
• For children, because pain is such a
different sensation than usual, pain is not
only a hurting sensation but it can also be a
very confusing one—the child did not
anticipate the pain, does not have words to
explain how it feels, and cannot always
understand its cause.
• In addition, preschoolers and younger
children lack an understanding of time,
which makes it difficult to explain to them
when the pain will go away.
• Both helping children describe the type and
extent of pain they are feeling and
performing active interventions to relieve
pain are some of the most important
nursing roles in children’s care.
• Assessing for pain is so important that pain
is often considered the “fifth vital sign”
PAIN AND CHILDREN
• Many children are undermedicated
because of common misperceptions about
pain in children
• Nonpharmacologic interventions should be
employed
• Combinations of pharmacologic and
nonpharmacologic interventions are often
most effective
• Anesthetic cream should be used if possible
• Medication routes preferred are oral and
intravenous
• Conscious sedation should be used for
painful and frightening procedures
PHYSIOLOGY OF PAIN
• As in adults, acute pain in children usually
occurs for one of four reasons: reduced pH
alterations which cause depletion of
oxygen in tissues, pressure on tissue,
external injury, or overstretching of body
cavities with fluid or air.
• Chronic pain often involves irritation of
nerves and/or tissue, which can occur with
the pain of shingles, fibromyalgia, or other
long-term injuries and irritations.
• The stimulus causing pain is not always
visible or measurable. In addition, anxiety
can lead to increased pain regardless of
the physical stimuli.
• Pain conduction consists of four major steps:
transduction (sensing the pain sensation),
transmission (routing the pain sensation to
the spinal cord), perception (the brain
interprets the sensation as pain), and
modulation (steps the body takes to
relieve pain).
• Pain impulses join central nervous system
(CNS) fibers in the dorsal horn of the spinal
cord. Here, the impulses are projected
upward to the brain, where they will be
perceived as pain.
ACUTE PAIN
• means sharp pain. It generally occurs
abruptly after an injury. The pain of a
pinprick is an example.
CHRONIC PAIN
• is pain that lasts for a prolonged period or
beyond the time span anticipated for
healing.
• Acute pain usually causes extreme distress
and anxiety; chronic pain can lead to
depression and decrease patient’s ability
to achieve relief as the threshold to sense
pain lowers and creates a “feedback loop”
• This is also referred to as hyperalgesia
which is defined as an increased sensitivity
to pain and is seen when patients have a
heightened response to minimal painful
stimuli.
CUTANEOUS PAIN
• is pain that arises from superficial structures
such as the skin and mucous membrane. A
paper cut is an example.
SOMATIC PAIN
• is pain that originates from deep body
structures such as muscles or bones. The
pain of a sprained ankle is somatic pain.
VISCERAL PAIN
• involves sensations that arise from internal
organs such as the intestines. The pain of
appendicitis is visceral pain
52
REFERRED PAIN
• is pain that is perceived at a site distant
from its point of origin. The pain of right
lower lobe pneumonia, for example, is
often first thought to be abdominal pain
because the pain is referred or felt in the
abdomen.
PAIN THRESHOLD
• A child’s pain threshold refers to the point
at which the child first senses pain. This
varies greatly from person to person and is
probably most influenced by heredity.
PAIN TOLERANCE
• All people also have a point above which
they are not willing to bear any additional
pain.
• Pain tolerance levels are probably most
affected by cultural influences.
GATE CONTROL THEORY OF PAIN
• The gate control theory of pain attempts to
explain how pain impulses travel from a
site of injury to the brain, where the
impulse is registered.
• This theory envisions gating mechanisms in
the substantia gelatinosa of the dorsal horn
of the spinal cord that, when activated, can
halt an impulse at that level of the cord.
• This prevents the pain impulse from being
received at the brain level and interpreted
as pain.
2020 NATIONAL HEALTH GOALS RELATED
TO ALLEVIATING PAIN
• Reduce the proportion of patients suffering
from untreated pain due to a lack of
access to pain treatment.
• Reduce serious injuries from the use of pain
medicines.
• Reduce the number of non–U.S. Food and
Drug Administration (FDA)-approved pain
medications on the market.
• Reduce deaths from the use of pain
medicines
 Nurses can help the nation reduce pain
among children by active management of
pain as well as by teaching children about
the importance of avoiding painful
unintentional injuries by the use of safety
belts and bicycle helmets.
ASSESSING THE TYPE AND DEGREE OF PAIN
• Pain assessment can be difficult with
children not only because children have
difficulty describing pain but also because
some children will suffer with pain rather
than report it, unaware that someone could
make it go away.
• Other children may distract themselves by
methods such as concentrating on play.
Others may sleep, not from comfort but
from the exhaustion caused by the pain.
• All of these factors can make using only
subjective measures to assess pain, such as
observation, misleading trying to be brave.
Some may be reluctant to say they have
pain because they are afraid they will
receive a “shot” to relieve it, which will
cause more pain.
• Keeping in mind each child’s
developmental level as well as chronologic
age are important when assessing pain
because assessment varies widely from that
of a nonverbal infant to a very verbal
adolescent
THE INFANT
• In the past, it was believed that infants do
not feel pain because of incomplete
myelination of peripheral nerves.
• Evidence-based practice has shown this not
to be true because myelination is not
necessary for pain perception.
• A second argument in the past against
needing to provide pain relief for infants
was that they have no memory.
• It can be shown, however, that physiologic
changes occur with pain even in preterm
infants, so even with a lack of memory, it is
clear that pain is experienced.
• Other clues are diffuse body movements;
tears; a highpitched, harsh cry; a stiff
posture; alterations in facial expression
such as eyes squeezed shut; a quivering
chin; lack of play; and fisting
• Perhaps, the chief mark in infants, however,
is that when pain is present, they cannot be
comforted completely.
• When working with any infant, be sensitive
to situations that could cause pain
THE TODDLER AND THE PRESCHOOLER
• Determining when and how much pain is
present continues to be difficult with
toddlers and preschoolers because they
may not have a word in their limited
vocabularies to describe the sensation they
feel because words such as “sharp,”
“nagging,” or “aching” have little meaning
until a child has experienced each type
53
• Parents often encourage children of this
age to refer to pain as “my boo-boo” or to
use other word such as “hurt” or “ouchie,”
so children often are not sure if what you
mean by the word “pain” (to be most
accurate in assessment, use the child’s term
for pain or teach the child that “pain” is the
same as “boo-boo”).
• Children also can have difficulty comparing
the pain they feel now to past pain (e.g., Is
it better or worse?) because they have had
so little experience with pain.
• For some toddlers, pain is such a strange
sensation that aside from crying in
response to it, they may react aggressively
(e.g., pounding, rocking) as if to fight it off.
They also may avoid being touched or
held.
• Preschool children can describe that they
have pain but continue to have difficulty
describing its intensity.
• They begin to use comforting mechanisms,
such as gritting teeth, pressing a hand
against a forehead, pulling on their ear,
holding their throat, rubbing an arm, or
grimacing, to control or express pain.
• Some preschoolers do not think to mention
they have pain because they believe it is
something to be expected or, because of
their egocentric thinking, they assume
adults are already aware of their pain.
• They also may think pain is punishment for
some act, so this is what they deserve.
• It is sometimes difficult to comfort children
of this age during painful procedures by a
statement such as “It’s only for a minute”
because they do not yet have a perception
of time.
• Still, other behavior changes you may see
in preschoolers are regression or
withdrawal. To help evaluate if they have
pain, ask yourself, “What would this child
normally be doing?” (e.g., playing, eating,
sleeping).
• Input from parents on how their child
usually behaves can be valuable in an
evaluation. If a trial dose of analgesia is
used, you can then evaluate behavior
changes after the dose is given.
• Children who resume their usual behavior
after analgesia were probably in pain
before the analgesia took effect
THE SCHOOL-AGE CHILD AND THE
ADOLESCENT
• Children who think concretely can have
difficulty envisioning that a word like
“sharp” applies both to knives and to the
feeling in their abdomen.
• Because of this, they continue to have
difficulty describing pain.
• They may also assume, like preschoolers,
that you, as an authority figure, already
know they have pain.
• Children may be in middle school before
they can understand how to use a
numerical pain rating scale or that the
scale intensifies from left to right. Doing
preassessment work with them, such as
giving them 10 different-sized triangles
and asking them to arrange them from
smallest to largest, is a good way to
evaluate if they understand incremental
measurements or “least to most” and are
primed to describe pain intensity in a
measurable way.
• A scale of 1 to 5 can be used in younger
children if 1 to 10 seems overwhelming. If
it seems clearer, you can turn a pain rating
scale vertically so it measures bottom (little
pain) to top (a lot of pain) to help a child
learn incremental measurement.
• Adolescents are able to use adult pain
scales for assessment and also commonly
use adult mechanisms for controlling pain
such as grimacing or verbal outbursts.
• Some try to be stoic or not show pain in
order to avoid stereotypes of “crybaby” or
“chicken.”
• This tendency makes an assessment for
body motions that could indicate pain, such
as clenched hands, clenched teeth, rapid
breathing, and guarding of body parts,
doubly important to observe.
• This is also the age when concerns about
addiction may begin to appear.
COMMON FALLACIES ABOUT PAIN IN
CHILDREN
54
Pain Assessment
• A variety of pain rating scales have been
devised to use with children.
• None have been proven to be consistently
better than the others, mainly because both
children and the type of pain they can be
experiencing vary so much.
• As a rule, pick a well- documented
effective scale and urge your care team to
use that consistently for each child rather
than asking a child to adapt to different
assessment techniques.
• Be sure to follow the specific instructions for
that scale.
THE POKER CHIP TOOL
• The Poker Chip Tool uses four red poker
chips placed in a horizontal line in front of
the child. The technique can be used with
children as young as 4 years of age,
provided the child has some concept of
“more” or “less.”
• To use the tool, tell the child, “These are
pieces of hurt.” Beginning at the chip
nearest the child’s left hand and ending at
the one nearest the child’s right hand, point
to the chips and say, “This is a little bit of
hurt, this is a little more hurt, this is more
hurt, and this [the fourth chip] is the most
hurt you could ever have.”
• Then, ask the child, “How many pieces of
hurt do you have right now?” Children
without pain will reply they don’t hurt;
others will point to one of the poker chips.
• To gain more understanding of how much
pain the child is feeling, clarify the child’s
answer by a follow-up question such as
“Oh, you have a little hurt? Tell me about
that.”
THE PAIN EXPERIENCE INVENTORY
• The Pain Experience Inventory is a tool
consisting of eight questions for children
and eight questions for the child’s parents.
• It is designed to elicit the terms a child uses
to denote pain and what actions a child
thinks will best alleviate pain.
• Such a form can be used when a child is
admitted to an acute care facility or on an
initial home care visit. If possible, it should
be used before the child has pain
THE CRIES NEONATAL POSTOPERATIVE
PAIN MEASUREMENT SCALE
• The CRIES Neonatal Postoperative Pain
Measurement Scale is a 10-point scale
named for five physiologic and behavioral
variables commonly associated with
neonatal pain:
• C = crying;
• R = requires increased oxygen
administration;
• I = increased vital signs;
• E = expression;
• S = sleeplessness
THE COMFORT BEHAVIOR SCALE
• The COMFORT Behavior Scale is a pain
rating scale devised by nurses to rate pain
in very young infants
• On the first part of the scale, six different
categories (alertness, calmness/agitation,
crying, physical movement, muscle tone,
and facial expression) are rated from 1 to
5. The lowest score is 6 (no pain), and 30 is
the highest (a great deal of pain).
• In addition to rating physical parameters,
the infant is then observed for 2 minutes
and the evaluation of the baby’s pain is
documented on an analog (1 to 10) visual
scale.
THE FLACC PAIN ASSESSMENT TOOL
• The FLACC Pain Assessment Tool is a scale
by which healthcare providers can rate a
young child’s pain when a child cannot give
input, there is a language barrier, or the
child has a developmental delay.
• It incorporates five types of behaviors that
can be used to rate pain: facial expression,
leg movement, activity, cry, and
consolability.
• Because a child does not provide active
input, older children may prefer a pain
rating system in which they actively
participate.
WONG-BAKER FACES PAIN RATING SCALE
• This scale consists of six cartoonlike faces
ranging from smiling to tearful.
• Explain to the child that each face from left
to right corresponds to a person who has
no hurt up to a lot of hurt
55
• Use the words under each face to describe
the amount of pain the face represents.
• Next, ask the child to choose the face that
best describes the child’s pain and record
the number under the face the child
chooses.
The scale is popular with young children
and can be used for those as young as 3
years of age
• The scale is widely used by healthcare
providers because this appeal to children
makes the evidence-based tool easy to use
in practice
THE OUCHER PAIN RATING SCALE
• The Oucher Pain Rating Scale consists of six
photographs of children’s faces
representing “no hurt” to “biggest hurt you
could ever have.” Also included is a vertical
scale with numbers from 0 to 100.
• To use the photograph portion, point to
each photograph and explain what each
photo represents.
• Ask the child to point to the photo that best
represents the child’s degree of hurt. To use
the numbered scale portion, point to each
section of the scale and explain that 0
means “no hurt,” 1 to 29 means “a little
hurt,” 30 to 69 means “middle hurt,” 70 to
99 means “big hurt,” and 100 means “the
biggest hurt you could ever have.”
• Ask the child to point to the section of the
scale that represents the present level of
hurt. Children as young as 3 years of age
can use the tool by pointing to the
photograph that best describes their level
of pain.
• If the child can count to 100 by ones and
understands the concept of increasing
value, the numbered scale can be used.
• The Oucher scale has White, Black, and
Hispanic American photograph versions. If
children are most comfortable with the tool,
allow them to select the version they want
to use or present the version that most
closely matches the cultural characteristics
of the child.
THE NUMERICAL OR VISUAL ANALOG
SCALE
• The numerical or visual analog scale (Fig.
39.3) uses a line with end points marked “0
= no pain” on the left and “10 = worst
pain” on the right. Divisions along the line
are marked in units from 1 to 9.
• Explain to children that the left end of the
line (0) means that a person feels no pain.
At the other end is a 10, which means that
a person feels the worst pain possible.
• The numbers 1 to 9 in the middle are for
“a little pain” to “a lot of pain.” Ask
children to choose a number that best
describes their pain.
• As soon as they can count and have a
concept of “less to more,” children are
ready to use a numerical scale.
• Be certain to show school-age children the
scale; do not just say score your pain from
0 to 10. Until children reach late
adolescence, they use concrete thought
processes and so need the help of seeing
the line to rate their pain best.
THE ADOLESCENT PEDIATRIC PAIN TOOL
• The Adolescent Pediatric Pain Tool (APPT)
combines a visual activity and a numerical
scale
• On one half of the form is an outline figure
showing the anterior and posterior view of
a child. To use the tool, tell a child to color
in the figure drawing at the point where
pain is felt. In addition, on the right side of
the form, tell the child to rate the present
pain in reference to “no pain,” “little pain,”
“medium pain,” “large pain,” and “worst
possible pain.”
• For a third activity, tell children to point to
or circle as many words as possible on the
form that describe their pain (words such as
horrible, pounding, cutting, and stinging).
• The scale is suggested for use in children 8
through 17 years of age.
• Reading the words together helps children
examine the type, location, and level of
56
 pain they are experiencing. It also helps
parents to better understand what their
child is experiencing.
LOGS AND DIARIES
• Having children keep logs or diaries in
which they note when pain occurs and the
intensity of the pain each time it occurs can
be useful for assessing children with chronic
but intermittent pain.
• Examining such a diary not only reveals
when pain occurs but also provides
direction for pain management.
• For example, if the diary shows the child
always awakens with pain in the morning,
the child may need a longer acting
analgesic to take at bedtime; if pain is
worse during weekends spent at a
grandparent’s house, investigate whether
something different is happening in that
setting than at home that could be causing
increased pain.
NURSING DIAGNOSIS
• Pain related to an invasive procedure
• Fear related to anticipation of a painful
procedure
• Disturbed sleep pattern related to chronic
pain
• Anxiety to planned dressing changes that
cause pain
QSEN
• Patient-centered care
• Teamwork and collaboration
• Evidence-based practice
• Quality improvement
• Safety
• Informatics
PAIN MANAGEMENT
• Pain management techniques, like
assessment techniques, vary greatly
depending on the age of a child and the
degree and type of pain a child is
experiencing.
• Many healthcare agencies employ nurses
specially prepared in pain management to
serve on an interprofessional team of
healthcare providers, including physicians,
anesthesiologists, patient advocates, and
wound therapy nurses, to plan individual
pain management programs for children
• Children with chronic pain or pain not
relieved with standard approaches may
benefit from a referral to a pain
management specialist or team because
relief of frequent pain episodes or
prolonged pain may require intense,
consistent assessments and interventions,
which are difficult to achieve in an acute
care setting or during infrequent office
visits.
• Whatever assessment tools or methods of
pain relief are used, the staff should all
become familiar and comfortable with their
use, so interventions do not vary based on
the healthcare provider.
NONPHARMACOLOGIC PAIN
MANAGEMENT FOR CHILDREN
• Nonpharmacologic pain relief measures
(often called alternative or complementary
therapies) can be used either
independently or as complements to
pharmacologic pain relief.
DISTRACTION
• Distraction techniques aim at shifting a
child’s focus from pain to another activity
or interest
• Blowing soap bubbles, for example, could
be used during an injection to accomplish
this. If oral glucose is offered to infants
during painful procedures, the pain they
experience appears to be significantly less
• It is hypothesized that drinking glucose not
only serves as a distraction technique but
also activates endorphins and produces a
central analgesic effect
• Breastfeeding may also be used in this
way but is not advised to avoid the infant
making an association between
breastfeeding and pain. When helping
57
 parents choose a distraction technique such
as blowing soap
SUBSTITUTION OF MEANING OR IMAGERY
• Substitution of meaning or guided imagery
is a distraction technique to help a child
place another meaning (a nonpainful one)
on a painful procedure
• Children are often more adept at imagery
than adults because their imagination is less
inhibited.
• This technique works well with both quick,
simple procedures such as venipunctures
and chronic pain. Success with this
technique requires practice, however, so it
may have limited application in an acute
care setting.
• As an example, a child could imagine a
venipuncture needle as a silver rocket ship
probing the moon or a submarine diving
under the water to escape a torpedo just in
time.
• Be certain a child thinks of a specific
image. Help the child elaborate on the
image to make it more concrete each time
it is used by asking questions
• This helps the child’s mind stay on the
image and not the venipuncture pain.
THOUGHT STOPPING
• Thought stopping is a technique in which
children learn to stop anxious thoughts by
substituting a positive or relaxing thought in
its place.
• As with imagery, this technique requires
practice before it can be used in a painful
situation. It may be most helpful in relieving
anticipatory anxiety, a negative force that
not only increases a pain experience
during a procedure but also makes the
time before it full of anxiety as well.
• For this technique, help children think of a
set of positive things about the
approaching feared procedure.
• For a bone marrow aspiration, for
example, this might include “It doesn’t take
long; my father will be with me; it’s
important to help me get better.”
Whenever children start to think about the
impending procedure, they should stop
whatever they are doing and recite the list
of positive thoughts to themselves if others
are present or out loud if they are alone or
only important support people are present.
• Children can then return to a usual activity.
Every time the anxious thoughts appear,
however, a child should stop and recite the
list again
• Thought stopping is different from merely
saying “Don’t think about it.” because the
technique does not suppress thoughts;
rather, it changes them into positive ones. It
also gives children a feeling of control. The
secret for success is for the child to use the
technique every time the disturbing,
anxious thoughts appear even if, at first,
such thoughts crowd in as frequently as
every few minutes.
HYPNOSIS
• Hypnosis is not a common pain
management technique with children but
can be effective if a child is properly
trained in the technique
• For best results, a child needs to train with
a therapist before anticipated pain, so at
the time of the pain, the child can produce
a trancelike state to effectively avoid
sensing pain
AROMATHERAPY AND ESSENTIAL OILS
• Aromatherapy is based on the principle
that the sense of smell plays a significant
role in overall health. When an essential oil
is inhaled, its molecules are transported via
the olfactory system to the limbic system in
the brain. The brain then responds to
particular aromas with emotional
responses. When applied externally, the
oils are absorbed by the skin and then
carried throughout the body within 15
seconds
• Essential oils may be able to penetrate cell
walls and transport nutrients or oxygen to
the inside of cells.
• Jasmine and lavender are oils thought to
be responsible for relieving pain
MAGNET THERAPY
• Magnet therapy is based on the belief that
magnets can control or shift body energy
lines to restore health or relieve pain.
Magnets can be applied as jewelry or
sewn into clothing or shoes. Although many
people find relief from magnet therapy,
the relief may be more of a placebo effect
than an actual change in pain level
• Copper also is believed to have pain-
relieving ability and is often incorporated
into rings and bracelets for this reason.
58
 MUSIC THERAPY
• The use of music for calming or improving
well-being can be effective for all ages of
children or adolescents, even as young as
preterm infants. It works to relieve pain
because it can be relaxing and also serves
as a distraction
• A child who is “blasting” music from a
phone or iPad may not actually enjoy
hearing the music that loud but needs that
level of distraction to feel free of pain.
YOGA AND MEDITATION
• Yoga, a term derived from the Sanskrit
word for “union,” involves a series of
exercises that were originally designed to
bring people who practice it closer to
spirituality. It offers a significant variety of
proven health benefits, such as increasing
the efficiency of the heart, slowing the
respiratory rate, lowering blood pressure,
promoting relaxation, reducing stress, and
allaying anxiety.
• Exercises consist of deep-breathing
exercises, body postures to stretch and
strengthen muscles, and meditation to focus
the mind and relax the body. Yoga may
be helpful at reducing pain through its
ability to create total relaxation and
possibly through distraction or the release
of endorphins
ACUPUNCTURE AND ACUPRESSURE
• Acupuncture involves the insertion of
needles into critical positions (meridian
lines) in the body to achieve pain relief
(Chiou & Nurko, 2010). Acupressure
involves applying deep pressure at the
same points. Although acupuncture is almost
painless, children can be very afraid of it
at first because of the sight of the needles.
This level of stress can make it not as
attractive an option for pain management
with children as acupressure.
• Children who consent to either technique,
however, particularly those with chronic
pain, report that the overall process is
pleasant and the method offers relief from
stress
CRYSTAL OR GEMSTONE THERAPY
• Some people believe gemstones or crystals
have healing powers when they are
arranged in certain positions around the
body. If these are being used, be careful
when changing bedding or rearranging
equipment in a child’s room that you do not
tip them over or move them. A child may
feel they may lose their pain-relieving
powers if placed in a different position
HERBAL THERAPIES
• Specific herbs are frequently used for
relieving pain or for generally improving
children’s health. Some examples include
chamomile tea (inflammation reduction),
garlic (anti-inflammatory reduction,
anticancer prevention), ginger (nausea or
vomiting reduction), goldenrod (urinary
tract inflammation reduction), or
peppermint (abdominal pain relief)
• Always ask when taking health histories if a
child is being given any herbs to be
informed about common herbs and to be
certain what the child is receiving will
complement, and not interfere with, the
effects of prescribed pain medication.
BIOFEEDBACK
• Biofeedback is based on the theory people
can regulate internal events such as heart
rate and pain in response to a stimulus
• A biofeedback apparatus is used to
measure muscle tone or the child’s ability to
relax. Biofeedback can be effective with
adolescents but is less effective with school-
age and younger children because they
tend to resist the biofeedback information
or cannot concentrate for long enough for
training to be optimal.
• Although some children grasp the technique
in one demonstration session, most need to
attend several sessions to condition
themselves to adequately regulate their
pain response.
THERAPEUTIC TOUCH AND MASSAGE
• Massage is the use of rubbing or kneading
of body parts to aid circulation and relax
muscles. Therapeutic touch is the use of
touch to provide comfort and relieve pain
• Therapeutic touch is based on the principle
that the body contains energy fields. When
these are plentiful and arranged correctly,
they lead to health; when they are in lesser
supply, ill health results.
• Although therapeutic touch may serve as a
form of distraction, proponents believe it is
possible to redirect energy fields to
increase the supply and the release of
endorphins.
TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION
• Transcutaneous electrical nerve stimulation
(TENS) involves applying small electrodes
59
 to the dermatomes that supply the body
portion where pain is experienced
• When children sense pain, they push a
button on a control box, which then delivers
a small electrical current to the skin.
• The principle underlying this technique is
the same as rubbing an injured part or
acupressure—the current interferes with the
transmission of the pain impulse across
small nerve fibers.
• TENS can be used to manage either acute
or chronic pain.
• TENS is not recommended if the child is
incontinent or has a wound that is likely to
cause the electrodes to get wet. Skin should
also be monitored for irritation from the
TENS pads.
HEAT OR COLD APPLICATION
• Cold reduces pain by constricting
capillaries and therefore reducing vessel
permeability and edema and pressure at
an injured site.
• After the first 24 hours of an injury,
applying heat may be more helpful
because this dilates capillaries, increases
blood flow to the area, and again helps
reduce edema.
PHARMACOLOGIC PAIN RELIEF
• Pharmacologic pain relief refers to the
administration of a wide variety of
analgesic medications. Many children need
analgesic agents in addition to
nonpharmacologic techniques for pain
relief, especially for acute pain.
• Medications can be applied topically or
given orally, intramuscularly, intravenously,
or by epidural injection.
• As a rule, intramuscularly administered
analgesia should be avoided in children
because children dislike injections and have
a limited number of adequate injection
sites.
• Be certain children understand that it is
acceptable to ask for medication for pain
because they may not know they can do so
unless this is stressed by healthcare
providers.
TOPICAL ANESTHETIC CREAM
• To reduce the pain of procedures such as
venipuncture, lumbar puncture, and bone
marrow aspiration, a local anesthetic
cream that contains 4% lidocaine can be
used
• The cream is applied to the skin, and the
site is then covered with an occlusive
dressing or plastic wrap to keep young
children from wiping away or tasting the
cream.
• The time needed for effect between
different brands varies from 30 minutes to
1 hour and so must be applied within that
time frame before an expected procedure
• Parents can apply anesthetic cream at
home before bringing a child to a clinic
visit for a procedure such as bone marrow
aspiration to avoid a long waiting time
• EMLA cream, a combination of local
anesthetics, is a popular cream used but
has to be applied at least 1 hour before
the procedure; however, it can be applied
up to 3 hours before a procedure and still
be effective. A newer compound, ELA-MAX
(LMX), containing only lidocaine, takes
effect in 30 minutes or less
• Caution them not to allow their child to
remove the dressing because the cream
could anesthetize the gag reflex if eaten
or cause eye damage if rubbed into the
eyes. They are effective with procedures
such as venipuncture, intramuscular (IM), or
subcutaneous injections. They also can be
used effectively for pain relief with
circumcision
• It can be purchased without a prescription
but, as an over-the-counter medication, is
often not reimbursed by insurance
companies.
ORAL ANALGESIA
• Oral analgesia is advantageous because it
is cost-effective and relatively easy to
administer. Many analgesics are supplied
in liquid form and flavored with cherry or
grape syrup to disguise unpleasant tastes.
• Nonsteroidal anti-inflammatory drugs
(NSAIDs) such as ibuprofen or naproxen
are excellent for reducing pain because, as
their name implies, they reduce
inflammation as well as pain in conditions
such as sprained ankles or rheumatic
conditions.
• Children should not receive acetylsalicylic
acid (aspirin) for pain relief, especially in
the presence of flulike symptoms, because
there is an association between aspirin
administration and the development of
60
 Reye syndrome, a severe neurologic
disorder
• For managing severe or acute pain, such as
postoperative pain or the pain of a sickle-
cell crisis, opioids, such as morphine,
oxycodone, and hydromorphone
(Dilaudid), are frequently prescribed.
Because this class of drugs is also referred
to as narcotics or opioids, parents may be
reluctant to give their children these
medications out of concern that their child
will become addicted.
• Acknowledge their concern but reassure
them the risk for addiction during short-
term use is remote.
• Reinforce that the main concern is supplying
adequate pain relief for their child.
INTRAMUSCULAR INJECTION
• Although opiates are available as IM
injections, analgesia for children is rarely
given by this route because the number of
suitable injection sites in children is limited,
injections are associated with pain on
administration, and such an injection can
produce great fear in children.
• An IM injection also can lead to several
risks, including uneven absorption,
unpredictable onset of action, and nerve
and tissue damage. As a rule, other routes
are used whenever possible
INTRAVENOUS ADMINISTRATION
• IV administration of analgesia, the most
rapid-acting route, is the method of choice
in emergency situations, in the child with
acute pain, and in a child requiring
frequent doses of analgesia but in whom
the gastrointestinal tract cannot be used.
Common opioids given by this route include
morphine (no common brand name),
fentanyl (Sublimaze), hydromorphone
(Dilaudid), and methadone (no common
brand name).
• Opiate analgesics can be given by bolus
injection or by continuous infusion. If doses
will be given periodically by an IV line,
advocate for the use of an intermittent
infusion device to avoid repeated
venipunctures with each dose or the need
for a confining IV line to be in place. If a
child’s pain is frequent or constant so a
continuous IV line is necessary, advocate
for a patient-controlled pump to offer the
child a sense of control and rapid
analgesia.
• As the child becomes able to take
medications by mouth, oral forms of
analgesics will then be administered. When
switching from IV to oral medications, be
certain the oral medication is supplied in an
equianalgesic dose.
PATIENT-CONTROLLED ANALGESIA
• Patient-controlled analgesia (PCA) allows a
child or a parent to self-administer boluses
of medication, usually opioids, with an IV
medication pump
• Children as young as 5 or 6 years of age
are able to assess when they need a bolus
of medicine and press the button on the
pump to deliver the new dose through an
established IV line.
• Parents or a nurse are able to administer a
new dose to children younger than this as
long as the child is awake. Morphine is a
common analgesic used for PCA
administration
• The pump is set with a lockout time so that
after each dose, the pump will not release
further medication even if the button is
pushed again; because of this, children
cannot overmedicate themselves.
• If pain is constant, a continuous infusion
should be used so that pain relief continues
even while the child sleeps. The pump can
still be programmed for bolus dosing to
cover episodes of increased pain.
CONSCIOUS SEDATION
• Conscious sedation refers to a state of
depressed consciousness usually obtained
through IV analgesia therapy
• The technique allows a child to be both
pain free and sedated for a procedure.
• Unlike the use of general anesthesia,
protective reflexes are left intact and a
child can respond to instructions during the
procedure.
• The technique is used for painful
procedures such as dental extractions,
wound care, and bone marrow aspiration,
as well as for magnetic resonance imaging
and endoscopy, both of which require a
child to lie still for a long period of time
and can be potentially frightening.
• Drugs used for conscious sedation can be
something as common as chloral hydrate or
as involved as a sedative-hypnotic-
analgesic combination, which relieves both
anxiety and pain and depresses the child’s
memory of the event.
61
INTRANASAL ADMINISTRATION
• Intranasal administration is becoming an
attractive way to dispense medicine for
children because it’s easy for parents to
administer and the medicine absorbs well
from the nasal mucous membrane.
• Midazolam (Versed) is a short-acting
adjuvant sedative that can be administered
intranasally by nasal drops or nasal spray
before surgery or procedures such as
nuclear medicine scanning
• Because it has a very short duration of
action, it may require repeat
administration.
• Because it has no analgesic action, an
analgesic should be administered
concurrently if the procedure will be
painful.
LOCAL ANESTHESIA
• Local anesthetics stop pain transmission by
blocking nerve conduction of the impulse at
the site of pain. Children receive local
anesthetic injections, such as lidocaine,
before procedures such as bone marrow
aspiration, peritoneal dialysis, or suturing
of lacerations.
• For many children, the sight of the
anesthetic needle is so frightening that they
cannot listen to the assurance that the
momentary needlestick will actually
prevent further pain. The use of an
anesthetic cream before the injection can
be helpful to relieve the needlestick pain
and allow the anesthetic to numb the tissues
to prevent pain
EPIDURAL ANALGESIA
• Epidural analgesia, an injection of an
analgesic agent into the epidural space just
outside the spinal canal, can be used to
provide analgesia to the lower chest,
abdomen, and lower body for 12 to 24
hours or longer if needed.
• An opioid, often combined with a long-
acting anesthetic, is instilled continuously or
administered intermittently by a catheter
into the epidural space.
• Children who have orthopedic or chest
surgery, for example, may have an
epidural catheter inserted in the operating
room and then continue to receive
analgesia by this method to relieve
postsurgical pain
• This is a very effective route of analgesia
for the postoperative child in the first few
days after surgery.
• Some parents may be reluctant to allow
this type of analgesia because they equate
it with spinal anesthesia, which they know
can cause severe headaches. You can
assure them that an epidural needle does
not enter the cerebrospinal fluid, so spinal
headaches are extremely rare.
62